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DISEASES OF NUTRITION AND INFANT FEEDING 



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DISEASES OF NUTRITION 
AND INFANT FEEDING 



BY 

JOHN LOVETT MORSE, A.M., M.D. 

Professor of Pediatrics, Harvard Medical School; Visiting Physician at the 

Children's Hospital; Consulting Physician at the Infants' 

Hospital and the Floating Hospital, Boston 

AND 

FRITZ B. TALBOT, A.B., M.D. 

Instructor in Pediatrics, Harvard Medical School; Chief of Children's Medi- 
cal Department, Massachusetts General Hospital; Physician to Chil- 
dren, Charitable Eye and Ear Infirmary; Consulting Physician at 
the Lying-in Hospital and at the Floating Hospital, Boston 



SECOND EDITION 

REVISED 



Km flurk 
THE MACMILLAN COMPANY 

1920 

AU rights reserved 



•1 



6 



Coptsight, 1915, 1920, 
Bt THE MACMILLAN COMPANY 



Set up and electrotyped. Published September, 1918 
Reprinted October, 1915. 

New Edition Completely Revised January, 1920 



JAN 14 1920 



*3>C.IA561438 






PREFACE TO SECOND EDITION 

The aim of the second edition remains the same as that of the 
first edition. New data have been added which brings the litera- 
ture up to April 1, 1918. The exigencies of the war have retarded 
investigation to such an extent that during the past year there 
have been very few workers who were able to do anything to ad- 
vance the science of Pediatrics. These recent publications have 
not been included in the literature. 

John Lovett Morse, 
Fritz B. Talbot. 
August 6, 1919. 



PREFACE 

This book was written to meet what seemed to the authors to 
be two distinct needs in American pediatric literature; a detailed 
description of the scientific basis of rational infant feeding and a 
description of the method of infant feeding taught in the Harvard 
Medical School. In it the authors have endeavored to meet these 
needs. It is intended to satisfy the demands, on the one hand, of 
those students who wish to become acquainted in the original 
with the data on which the scientific basis of infant feeding rests 
and, on the other, of the general practitioner who wishes to learn 
the clinical and practical sides of infant feeding. It is hoped that 
it will not only point the way to further investigations but also 
be of service to the clinician in his daily work. 

John Lovett Morse. 
Boston, Fritz B. Talbot. 

September, 1915, 



TABLE OF CONTENTS 

SECTION I 

PHYSIOLOGY AND METABOLISM 

CHAPTER PAGE 

I. Physiology of Digestion 1 

II. The Digestion and Metabolism op Fat 20 

III. The Digestion and Metabolism op Carbohydrates . . 32 

IV. The Digestion and Metabolism op Protein .... 43 
V. The Metabolism op the Mineral Salts 58 

VI. The Energy Metabolism op Infants 64 

VII. Bacteriology op the Gastrointestinal Canal ... 77 
VIII. The Stools in Infancy 87 

section II 

BREAST FEEDING 

IX. General Considerations 99 

X. Human Milk: Chemistry and Biology 103 

XI. Clinical Considerations and Technique 134 

XII. Wet-Nurses 153 

section hi 
ARTIFICIAL FEEDING 

XIII. Cow's Milk: Chemistry and Biology 157 

XIV. Cow's Milk: Bacteriology and Chemical Tests . . . 175 
XV. Sterilization, Boiling and Pasteurization of Milk . . 179 

XVI. Certified Milk 189 

XVII. General Principles op Artificial Feeding .... 192 

XVIII. The Prescribing op Modified Milk 225 

XIX. The Feeding of Premature Infants 250 



x TABLE OF CONTENTS 

SECTION IV 

■ 

DISEASES OF THE GASTROINTESTINAL CANAL 

CHAPTER PAGE 

XX. Spasm op the Pylorus 255 

XXI. Hypertrophic Stenosis op the Pylorus 259 

XXII. Nervous Disturbances op the Digestive Tract . . . 267 

XXIII. Disturbances op Digestion 269 

XXIV. Indigestion with Fermentation . 291 

XXV. Infectious Diarrhea 302 

XXVI. Constipation 321 

section v 

DISEASES OF NUTRITION 

XXVII. Rickets 329 

XXVIII. Infantile Scurvy 341 

XXIX. Spasmophilia 354 

XXX. Acidosis 361 

Index 369 



DISEASES OF NUTRITION AND INFANT FEEDING 



SECTION I 
PHYSIOLOGY AND METABOLISM 

CHAPTER I 
PHYSIOLOGY OF DIGESTION 

MOUTH 

Food is drawn into the mouth of the infant by the negative 
pressure which results from the act of sucking. This nega- 
tive pressure is between five and fifteen centimeters of mer- 
cury or between ten and one hundred and forty centimeters of 
water. 1 

Almost all the work on the reaction of the oral cavity has been 
done by older writers and, although their results have not been 
uniform, it seems to be established that the reaction of the mouth 
of the new-born infant is neutral or weakly alkaline before the first 
food is taken. The acid reaction of the mouths of older babies is 
probably due to the breaking down of food remains. Oshima 2 has 
recently demonstrated lactic acid, by Uffelmann's test, in the 
mouths of infants, most often between the ages of three and six 
months. He attributes the presence of this acid to the action of a 
leptothrix. It probably is not present in large enough amounts 
to be of any practical importance. Immediately after birth a 
baby's mouth is free from bacteria, but it very quickly becomes 
infected. The normal bacterial flora, therefore, quickly gain 
entrance into the infant's gastrointestinal canal a few hours after 
birth. 

The weight of the salivary glands at different ages, as given by 
Berger, 3 is as follows: 

1 Gundobin: Die Besonderheiten des Kindesalters, Berlin, 1912, 248. 

2 Oshima: Arch. f. Kinderh., 1907, xlv, 21. 

3 Quoted by Gundobin: Die Besonderheiten des Kindesalters, Berlin, 1912, 



PHYSIOLOGY OF DIGESTION 



TABLE 1 





Average 

body 

weight 


Parotid 


Av. wt. 
both sub- 
maxillaries 
gm. 


Av. wt. 
both sub- 
linguals 
gm. 


Age 


Av. wt. 
gm. 


Max. wt. 
gm. 


Min. wt. 
gm. 


New born 
3 months 
6 months 
2 years 


3580 gm. 
3600 gm. 
4745 gm. 
9100 gm. 


1.80 
3.18 
4.50 
8.60 


2.4 

4.8 
5.8 
9.6 


0.9 
1.4 
3.1 

8.2 


0.84 
1.53 
2.12 

4.89 


0.42 
0.84 
1.05 
2.00 



These glands are heavier in healthy and well developed than in 
sickly and poorly developed infants, but considerable individual 
variations are often found. The glands begin to differentiate from 
the epithelium of the mouth in the second month of fetal life and 
can be dissected at the tenth week of fetal life. 

Saliva is secreted during the first week of life and probably dur- 
ing the first day (Joerg, Bidder and Schmidt). It has the power 
of converting starch into sugar as soon as it is secreted. 1, 2> 3i 4 
Ptyalin is present in both the parotid and submaxillary glands. 3 
Ibrahim was able to demonstrate diastatic ferments in both the 
parotid and submaxillary glands of two fetuses. One of them 
weighed but 150 gm.; the other was in the sixth month of fetal 
life. He thought that there was about the same amount in each 
gland at birth. The diastase in the saliva is only able to digest 
starches as far as maltose and not into grape sugar. 5, 6> 7 Shaw 8 
gave babies a test meal of barley water and washed out their stom- 
achs from fifteen to sixty minutes later. He found that it was 
possible for the diastatic action of saliva to continue in the stomach 
as long as two hours after feeding. It is difficult to say what role 
the saliva of infants plays in the physiology of digestion. Probably 
it plays a very small part. In general, it has been shown, 9 ' 10 * 11> 



1 Schlossmann: Jahr. f. Kinderh., 1898, xlvii, 116. 

2 Montague: Diss., 1899, Leiden; Montague: Centralbl. f. Inn. Med., 1900, 
a, 705. 

3 Schilling: Jahrb. f. Kinderh., 1903, Neue Folge, lviii, 518. 

4 Moll: Monatsschr. f. Kinderh., 1905-06, iv, 307. 

5 Musculus and Gruber: Zeitschr. f. Phys. Chem., 1878, ii, 177. 

6 Musculus and Mering: Zeitschr. f. Phys. Chem., 1878, ii, 403. 

7 Hamburger: Pfiuger Arch., 1895, lx, 543. 

8 Shaw: Albany Med. Annals, Jan., 1904, xxv, 148. 

9 Glinsky: Sitzung.d. Gesellsch. russ. Arzte zu. St. Petersburg, 1895. 
10 Wulfson: Diss. St. Petersburg, 1898. 
"Snarsky: Diss. St. Petersburg, 1901. 



PHYSIOLOGY OF DIGESTION a 

*■ 2 that the dryer the food, the greater the secretion of saliva. 
This rule, however, does not hold good with milk, 3 the food of 
babies, because considerably more saliva is secreted for a food 
containing milk than for that containing meat. It is admitted, 4 ' 
5 however, that saliva may cause coagulation of milk and thus 
help stomach digestion. The amount of water, albumen, and 
mucus in saliva varies considerably. 

Finizio 6 induced infants to suck bits of cotton and then deter- 
mined the amylolytic power of the saliva. This was greatest about 
midday and was different in babies of the same age. When the 
babies were less than six months old, it did not vary after nursing 
or when starch was added to the food, but when they were over six 
months old, there was an increase in the amylolytic power im- 
mediately after a meal containing starchy foods. This increase 
was still noticeable an hour later. Beginning at about six months 
there seemed to be a gradual development of the specificity of 
function of the salivary glands. He tested the saliva of several 
babies monthly during the first year and found that the amylolytic 
power increased progressively from birth to the age of twelve 
months. At eight to ten months it was twice that at birth, and 
at one year a trifle less than that of children two to three years old. 
Allaria 7 found that, after the first weeks of life, the mouth reacted 
acid to litmus paper and phenolphthalein, and that the reaction 
was rarely neutral or alkaline. 

STOMACH 

The stomach of the fetus, with the exception of the pylorus, lies 
completely in the left hypochondrium. The pylorus is in the 
median line and is completely covered by the liver. These rela- 
tions change after birth so that at fifteen months the liver no 
longer overlaps the stomach. The position of the stomach of the 
fetus is nearly vertical. In the newly-born child, it lies some- 
what obliquely in the abdomen, and at the end of infancy, it has 
almost reached the transverse position. 

The growth of the fundus compared with that of the stomach as 

1 Malloizel: Jour. d. Physiol, et Pathol., gener., 1902, 547. 
2 Heymann: Diss. St. Petersburg, 1904. 
3 Sellheim: Diss. St. Petersburg, 1904. 

4 Billard and Dieulate : Comptes rend, de la soc. de biol. a Paris, 1902. 
6 Borissow: Russk. Wrat. 1903, Die, letzen 8 Arbeiten, quoted in Noth- 
nagePs Handbuch. 

6 Finizio: Rev. Hyg. et Med. Infant, viii, No. 3, 224. 

7 Allaria: Monatsschr. f. Kinderh., x, No. 4, 179. 



4 PHYSIOLOGY OF DIGESTION 

a whole is relatively rapid during infancy. The length of the 
fundus of the fetus is one-fifth, of the infant one-quarter, and of 
the adult one-third of the total length of the stomach. 1 

The stomach, as would be expected, grows rapidly in size during 
the first year. The greater curvature becomes longer, increasing 
16 to 24 centimeters in length. Pisek and Lewald 2 conclude from 
their investigations with the Roentgen ray that there is no charac- 
teristic normal type of stomach in the infant. It is horizontal 
rather than vertical when compared with the adult type, and fol- 
lows certain rather definite forms. They distinguished (a) the 
ovoid or Scotch bag-pipe type of Flesh and Peteri (b), the tobacco 
pouch (retort shape of Alwens and Husler), and (c) the pear- 
shaped stomach with base above and to the left. The shape of 
the stomach does not depend on the amount or character of the 
food ingested, but rather upon the quantity of gas which it con- 
tains or acquires. Major 3 showed that the shape of the Roentgen 
ray picture of the stomach varied with the position of the infant 
and that the movements of the diaphragm could cause changes 
in its appearance. Alwens and Husler (quoted by Pisek 4 ) report, 
furthermore, that they have observed a change in the form from 
the tobacco pouch to the bag-pipe variety after the intestines 
have been emptied. 

Gastric Capacity. — Recent investigations show that the ana- 
tomic gastric capacity, obtained by measuring the capacity of the 
stomach by water poured in post-mortem at a pressure of 15 cm. 
(the figures given in most text-books are based on such observa- 
tions), is considerably smaller than the physiologic capacity. The 
physiologic capacity of infants' stomachs is at such variance with 
the anatomic measurements that it is safe to say that a baby can 
digest more than the anatomic size of the stomach would seem to 
warrant. 5 

The following figures were taken from Pfaundler, 6 and repre- 
sent the gastric capacity in cubic centimeters post-mortem with 
a pressure of 15 c. c. water. 

^undobin: loc. tit., 264. 

8 Pisek and Lewald: Am. Jour. Dis. Children, 1913, vi, 232. 
8 Major: Zeitschr. f. Kinderh., 1913, viii, 340. 
4 Pisek and Lewald : loc. tit. 
B Mosenthal: Arch. Ped., 1909, xxvi, 761. 

•Pfaundler: Magencapacitat im Kindesalter: Stuttgart, 1898, quoted by 
Gundobin. 



PHYSIOLOGY OF DIGESTION 





TABLE 


2 












Age of infant 


Months 


1 


2 


3 


4 


6 


8 


10 


12 


Systolic stomach 


150 


175 


210 
200 


235 
230 


290 
295 


360 
365 


430 

445 


4Q0 


Diastolic stomach. 


515 







The gastric capacity, determined post-mortem by Holt, 1 is as 
shown by Table 3. 

Tables 2 and 3 represent the gastric capacity of infants with 
closed pyloric valves which allowed no food to escape into the 
intestine. Mosenthal investigated the gastric capacity of in- 
fants during life (physiological capacity) and post-mortem (ana- 
tomic capacity), and found that the former was always larger 
than the latter. 









TABLE 


3 








Age 


No. of 


Capacity 


Age 


No. of 


Capacity 


cases 


oz. c. c. 


cases 


oz. c. c. 


Birth 


5 


1.2 


36 


7-8 mos. 


9 


6.88 


200 


2 weeks 


7 


1.5 


42 


10-11 " 


7 


8.14 


244 


4 


4 


2.0 


60 


12-14 " 


10 


8.90 


265 


6 


11 


2.27 


68 










8 


4 


3.37 


100 










10 


2 


4.25 


128 










12 


6 


4.50 


132 










14-18 " 


12 


5.00 


150 










5-6 mos. 


14 


5.75 


172 











The following table is a summary of the results which he ob- 
tained in a study of twenty-four cases: 



TABLE 4 

Amount of milk offered at each nursing 4.0 oz., 

Amount of milk ingested at each nursing 3.6 oz. 

Post mortem gastric capacity (Pfaundler's method) 2.6 oz., 



120 c. c. 

108 c. c. 

78 c. c. 



"In every instance, excepting the diastolic stomachs, the in- 
fant ingested more fluid at a nursing than the volume of its stomach, 
as determined by careful measurements, can contain." This means 
that the figures for gastric capacity given above represent the ana- 



5 Holt: Dis. Infancy and Childhood, N. Y. and London, 1911, 309. 



6 PHYSIOLOGY OF DIGESTION 

tomic capacity of the stomach, and that the physiologic capacity, 
what an infant can take at a nursing, can be considerably larger 
than this. This can be explained by the fact that shortly after 
milk is swallowed the stomach shows signs of motor activity and 
the milk begins to pass almost immediately into the intestines. 
This is proven by fluoroscopic examination which shows the milk 
spurting through the pylorus into the intestine before the meal is 
finished. This happens more easily with human milk than it 
does with simple dilutions of cow's milk. 

Duration of Stomach Digestion. — The duration of stomach diges- 
tion has been studied for a long time, at first with the stomach 
tube, 1, 2 * 3 ' 4f 5 only, and recently with the Rcentgen ray. 6, 7 It 
can be said in general on the basis of these observations, that 
the stomach digestion lasts in the breast-fed baby from one and a 
half to two hours, and in the artificially-fed baby three hours. 
Pisek and Lewald believe that a large number of stomachs practi- 
cally empty themselves within an hour, while A. H. Meyer, 8 and 
Von Monrad think that it is three and one-half hours before the 
stomach is emptied. A large meal obviously requires a longer 
period for digestion than a smaller one, and cow's milk remains 
longer in the stomach than human milk. 9 

Ladd's 10 extended series of observations on babies, and Cannon' 11 
on animals, have done much to increase our knowledge of this 
complicated subject. The infant's stomach, as compared with 
the adult's, shows a " curious lack of peristalsis." Shortly after 
food is ingested some of it may be discharged into the duodenum, 
without undergoing stomach digestion. It has been found in 
animals that carbohydrates leave the stomach the most rapidly 
of the three food components, a large part of them being discharged 
within two hours, while proteins are discharged less rapidly, and 
fats the most slowly. These facts fit in with the economy of the 
body, since carbohydrates are not digested at all by the gastric 
juices, and are, therefore, passed along to the small intestine as 

1 Epstein: Prager med. Wochenschr., 1880, 45, 450. 

2 Epstein: Prager med. Wochenschr., 1881, 33-34. 

3 Epstein: Jahr. f. Kinderh., 1887, xxvii, 113. 

4 Czerny: Prager med. Wochenschr., 1893, 495, u. 510 . 

5 Wohlmann: Jahr. f. Kinderh., 1891, xxxii, 297. 

8 Tobler and Bogen: Monat. f. Kinderh., 1908-09, vii, 12. 
7 Leven and Barret: Presse Medicale, 1906, 63, 503. 

9 Meyer, A. H.: Bibliothek f. Laeger, 8, R, III, 390-512. Kopenhagen, 
1902. Ref. im Jahr. f. Kinderh., 1903, Neue Folge, lviii, 275. 

Tobler and Bogen: Monat. f. Kinderh., 1908-09, vii, 12. 

10 Ladd: Am. Jour. Dis. Children, 1913, v, 345. 

11 Cannon: The Mechanical Factors of Digestion, London and N. Y., 1911. 



PHYSIOLOGY OF DIGESTION 7 

quickly as possible; whereas the proteins, which are digested by 
the gastric juices, are retained for this action. The fats, on the 
other hand, are discharged from the stomach at such a slow rate 
that there is never any great accumulation of fat in the small 
intestine, the rate of the discharge from the stomach being ap- 
proximately the same as that of the departure of fat from the small 
intestine. The discharge of mixtures of food depends upon the 
relative proportions of fat, carbohydrate and protein which they 
contain (Cannon). These findings in animals have been partially 
confirmed in a few observations on infants. In one instance, how- 
ever, in which the infant received food containing no fat, 6.62% 
sugar, and 3.5% protein, the stomach was not empty at the end 
of 1]4, hours. If, however, a fresh feeding is given before the 
stomach is empty, the bismuth feeding is frequently pushed out 
into the small intestine by the second meal. Tobler and Bogen l 
also found that milk mixtures containing much cream pass more 
slowly through the pylorus than those with low percentages of 
fat. 

Gastric Motility. — The motility of the stomach is in inverse 
proportion to the concentration of the food; in other words, the 
greater the dilution of the milk, the more rapidly the organ empties 
itself. 2 Carlson and Ginsberg 3 found that the empty stomach of 
the infant at birth, and of the prematurely born infant, exhibits 
the typical periods of tonus and hunger contractions of the adult. 
They conclude that in the normal mammal the mechanism of 
gastric hunger is completed physiologically at birth and is prob- 
ably active sometime before term. These findings have been 
recently confirmed by Taylor, 4 who also concluded from his in- 
vestigations that there is no appetite or psychic secretion of 
gastric juice in the young infant. In animals, the stomach is 
found to show signs of motor activity shortly after milk has been 
swallowed. According to the character of the movements of the 
gastric wall, two regions may be distinguished. The movements 
of the left hand, or cardiac part of the stomach, consist of slow, 
shallow, peristaltic waves, which gently push the food lying next 
to the gastric wall toward the pylorus. The cardiac part of the 
stomach acts as a reservoir, where the food lies undisturbed by 
any movement except such as is necessary to pass the peripheral 

1 Tobler and Bogen: Monatschr. f. Kinderh., 1908-09, vii, 12. 

2 Clark: Am. Jour. Med. Sciences, May and June, 1909, 674, 872. 
8 American Jour. Phys., 1915, xxxviii, 29. 

4 Am. Jour. Dis. Ch., 1917, xiv, 258; see also p. 254 of same for complete 
bibliography. 



8 PHYSIOLOGY OF DIGESTION 

layer on to the pyloric half. The state of affairs is different in the 
right half of the stomach. Five to eight minutes after the ingestion 
of food, deep peristaltic rings advance toward the pylorus and 
press the gastric contents strongly against the pyloric valve. The 
valve opens from time to time and allows some of the food to pass 
into the small intestine. 1, 2 It has thus been shown by Cannon, 
in his Roentgen ray work on cats, that the two parts of the stomach 
have two distinct functions, the left, or cardiac half, acting as a 
reservoir, in which the food lies practically undisturbed until it is 
passed on to the right or pyloric portion. Here it is thoroughly 
mixed under greater pressure, and is finally pushed into the small 
intestine. 

Tobler 3 was able to show, in a boy with a gastric fistula, that 
the coagulation of casein begins in from two to three minutes and 
is complete in ten minutes. This process is of great importance, 
since it is found that the fluid portion, containing the milk sugar 
in solution, is rapidly expelled from the stomach, while the curd, 
containing casein with fat entangled in its meshes, remains behind 
for further digestion. 4 Nature thus provides that too much fat 
is not set free at one time. The fluid gastric contents begin 
to pass through the pylorus before the infant has stopped 
nursing. 

The cardiac end of the stomach has a very delicate mechanism 
of its own by means of which it is at times closed, at others open. 
In cats the cardia is alkaline. As soon as it becomes acid, the car- 
diac orifice closes and remains so until the neighboring food com- 
ponents become alkaline. 5 The pyloric valve acts in a manner 
directly opposed to that at the cardia. When the material in the 
antrum pylori is acid, the valve opens and vice versa 6 . 

On the duodenal side of the pyloric valve an alkaline reaction 
allows the valve to open and an acid reaction causes it to close. 
Cowie and Lyon 7 found that the opening and closing reflex of the 
pyloric valve could also be demonstrated in infants. When the 
food was made acid the duodenal closing reflex is sustained and 
the evacuation of food from the stomach is consequently delayed, 
.even if the stomach contents are acid. Strongly alkaline food, on 
the other hand, causes the pyloric opening reflex to be delayed 

1 Cannon: Am. Jour. Phys., 1898, I, 359. 

2 Cannon: Am. Jour. Med. Sciences, 1906, cxxxi, 563. 

3 Tobler: Verhandl. d. Gesell., Kinderh., 1906, xxiii, 144. 
4 Moritz: Zeitschr. Biol., 1901, xlii, 565. 

6 Cannon: Am. Jour. Phys., 1908, 1909, xxiii, 105. 

6 Cannon: Am. Jour. Med. Sciences, 1906, cxxxi, 563. 

7 Cowie and Lyon: Am. Jour. Dis. Children, 1911, ii, 252. 



PHYSIOLOGY OF DIGESTION 9 

and as a result the food is retained longer in the stomach. Free 
hydrochloric acid is not necessary for pyloric opening in the in- 
fant, and it may provoke prolonged closing from the duodenal 
reflex. 

Solid particles of food may be pushed against the pylorus with- 
out opening the valve 1 and it is supposed that the curd of milk will 
have considerable mechanical influence on the opening and closing 
of the pylorus, while fat, whey, and lactose have little or no me- 
chanical action. Tobler 1 has also shown that the rapid inflation of 
a balloon in the duodenum checks the passage of food from the 
stomach. Cannon 2 believes that the evidence is opposed to the 
conception that mechanical agencies, acting either in the stomach 
or in the intestine, play an important part in controlling the 
normal gastric evacuation. 

Influence of Posture on Digestion and Emptying Time of 
Stomach. — Owing to the anatomical position of the cardia, air 
which is swallowed while nursing is prevented from escaping from 
the stomach while the infant is in the horizontal position because 
food acts as a water valve. The air can escape if the infant is 
upright and, therefore, it is better to hold the baby upright after 
nursing or during nursing. Distension with air causes discomfort, 
prevents the infant from taking the proper amount of food and 
causes vomiting. 3 

Fluroscopic examination of the stomach shows that the emptying 
time is markedly influenced by the position of the infant. There 
is comparatively slow motility in the supine position, and the 
stomach empties much more rapidly when the infant is on the 
right side than when it is on the left side. This phenomenon, 
which is almost constant, would seem to have clinical signifiance. 
It should prove to be of advantage to place infants on the right 
side when there is an evident delay in gastric digestion. 4 

Secretion of the Stomach. — Pepsin has been found in the 
stomachs of fetuses born at four and six months, 5, 6 and is always 
present in the stomachs of babies born at term. 7 Breast-fed babies 

1 Tobler: Zeitschr. Physiol. Chem., 1905, xlv, 185. 

2 Cannon: The Mechanical Factors of Digestion, London and New York, 
1911. 

3 Smith and Le Wald, Am. Jour. Dis. Ch., 1915, xi, 261. 

4 Hess: Am. Jour. Dis. Ch., 1915, ix, 461; De Buys and Henriques: Am. 
Jour. Dis. Ch., 1918, xv, 190. 

6 Langendorff: Arch. f. Anat. u. Physiol., 1879. 
•Huppert: Wiener Sitsungsberichte, 81, Abt. 3. 

7 Zweifel: Untersuchungen liber den Verdauungsapparat der Neugeborenen, 
Berlin, 1874. 



10 PHYSIOLOGY OF DIGESTION 

secrete less pepsin than artificially-fed babies. Rennin is prac- 
tically always present at birth. 1 There is no appetite or psychic 
secretion of gastric juice in the young infant. 2 Heubner 3 found 
lactic acid in babies' stomachs, but Sotow 4 and Hamburger and 
Sperk were unable to confirm these findings. A. H. Meyer ex- 
plained these conflicting results when he found that lactic acid 
appeared within two hours after the feeding of mixtures of cow's 
milk, and that it never appeared after a test meal of tea, or a 
"water meal." This makes it practically certain that the lactic 
acid found in the stomach is not the result of gastric secretion, 
but of the action of the stomach juices or of bacteria on the 
food. 

Engel 5 studied an infant of four weeks with a fistula in the 
upper duodenum, in which the connection between the stomach 
and duodenum was apparently cut off. The infant received noth- 
ing by mouth. Engel was able to collect from 100 to 200 cubic 
centimeters of gastric secretion per day by means of a small rubber 
tube passed through the mouth, and found in this pepsin, rennin, 
and free hydrochloric acid. He was unable to demonstrate a fat- 
splitting ferment or lactic acid. There is a difference of opinion 
concerning the presence of fat-splitting ferments in the stomach of 
infants from birth onward. Sedgwick 6 removed the stomach con- 
tents and fouud that they were able to split fat. This property is 
present at birth in rabbits and at a very early age in babies (in one 
case at two weeks) . Hess 7 found lipase in the stomach of the un- 
fed new-born infant. As much as 25% of the fat in the food can be 
split by the gastric juices, although it is believed that under normal 
conditions less than this is split. In infants between one and four 
months old, the lipase content of the stomach increases with the 
age of the infant. 8 Gastric lipase is easily destroyed by free 
hydrochloric acid 0.2%. 9 

Kramsztyk 10 found trypsin in a small proportion of the infants 
to whom oil test meals had been given. It is believed that this 

1 Hamburger and Sperk: Jahr. f. Kinderh., 1905, Neue Folge, brii, 
495. 

2 Taylor: Am. Jour. Dis. Ch., 1917, xiv, 258. 

3 Heubner: Jahr. f. Kinderh., 1891, xxxii, 27. 

4 Sotow: Diss. St. Petersburg, 1895. 

5 Engel: Archiv. f. Kinderh., 1909, xlix, 16. 

6 Sedgwick: Jahr. f. Kinderh., 1906, lxiv, 194; also, Arch. Ped., 1906. 

7 Hess: Am. Jour. Dis. Children, 1913, vi, 264. 

8 Hahn: Am. Jour. Dis. Children, 1914, vii, 305. 

9 Hull and Keeton: Jour. Biol. Chem., 1917, xxxii, 127. 

10 Kramsztyk: Przeglad Pedyatryczny, 1909, i, 209. 



PHYSIOLOGY OF DIGESTION 11 

tryspin has its origin in the pancreas and is regurgitated into the 
stomach. (Ibrahim.) 

Practically all of the factors present in the adult digestion are 
present in babies, but in a weaker form. 

Free Hydrochloric Acid. — Free hydrochloric acid is never found 
in the stomachs of some healthy breast-fed infants * while in others 
it is found regularly. 2 Hess 3 found it regularly in the stomachs 
of new-born infants even before food was given. Whether free 
hydrochloric acid is found or not in a given instance seems to 
depend upon the technique of the investigator. It may be said, 
in general, that the longer after a meal the stomach contents are 
tested, the more frequently hydrochloric acid is found. It is ob- 
vious that when a baby receives a food containing much casein, 
free hydrochloric acid will appear much later than when it receives 
a food which contains but little casein or other material with which 
hydrochloric acid can combine. 

Dundin 4 found that the reaction of the gastric mucous mem- 
brane of the fetus was always neutral up to the sixth month, 
after which it was acid. He was unable, however, to demonstrate 
free hydrochloric acid in any fetus. Hamburger and Sperk 5 
found small amounts in the stomachs of new-born babies from 
the third to the eighth day. The amount increases with the age 
of the baby (A. H. Meyer). About three times as much becomes 
" combined acid " on artificial feeding as on breast feeding. The 
acidity immediately after a meal is nil, but steadily increases dur- 
ing digestion, the rapidity of the increase varying directly with 
the age of the child. Free hydrochloric acid appears in a few min- 
utes after a feeding of barley water. It does not appear, however, 
for an hour or more after a feeding of milk, the delay being due 
to the power of casein to absorb and combine with acid. Free 
acid appears later in disease than in health. 6 It is interesting to 
note that the breaking down of sugar into lactic acid is retarded 
by the presence of from .01% to .02% of hydrochloric acid and 
prevented by .07% to .08%. The power of casein to delay the 
appearance of free hydrochloric acid explains the fact that lactic 

1 Heiman: Arch. Ped., 1910, xxvii, 570; Labbe: Rev. mens. d. mal. de 
l'enfance, 1879, xv, 401. 

2 Cassel: Arch. f. Kinderh., 1890, xii, 175; Wohlmann: Jahrb. f. Kinderh., 
1891, xxxii, 297. 

3 Hess: loc. cit. 

4 Dundin: quoted by Gundobin, Die Besonderheiten des Kindesalter, 
Berlin, 1912, 269. 

6 Hamburger and Sperk: Jahrb. f. Kinderh., 1905, brii, 495. 

7 Clark: Am. Jour. Med. Sciences, May and June, 1909, 672, 872. 



12 PHYSIOLOGY OF DIGESTION 

acid is frequently present in the stomachs of babies fed on cows' 
milk. 1 ' 2 ' 3 

The recent studies of Hahn 4 of the hydrogen-ion concentration 
of the gastric contents have added light from another point of 
view. He found that the acidity of the stomach juices, when stud- 
ied in this manner, was strikingly constant being (H) = 1.0 X 10~ 5 . 
This is in striking contrast to the figures given above of the titrable 
acidity, and is considered to be the normal acidity of the stomach 
contents at the height of digestion, when the food is either one- 
third or two-thirds milk. He believes that this is the optimum 
acidity for the action of rennet and gastric lipase and that it in- 
hibits the action of pepsin. 

Our conception of the therapeutic action of alkalies in modifying 
gastric digestion has recently been changed. It has been claimed 
by Southworth 5 and others, on the basis of the work of Van Slyke 
and Hart, that lime water and sodium bicarbonate neutralize the 
hydrochloric acid secreted in the stomach, and thus delay the 
coagulation of milk by rennin. As the result of this delay a por- 
tion of the milk is allowed to pass into the duodenum before co- 
agulation takes place. The amount of alkali given should be cal- 
culated in relation to the amount of milk and cream used in the 
mixture and not to the total quantity of the mixture, because the 
milk and cream alone contain casein and it is the casein which is 
acted upon by the rennin. This seems to be the most reasonable 
view to take at present. Clark 6 claims, however, that lime water 
does not reduce the acidity of the gastric contents, and that the 
neutralization of a portion of the acid is overcome by an increased 
stimulation of the gastric glands to form hydrochloric acid. The 
amount of acid available for digestion may thus be even increased. 
These findings presumably apply also to bicarbonate of soda. The 
evidence in relation to this subject is conflicting and it is by no 
means certain that the present conception of the action of alkalies 
will not be greatly modified by future investigations. The action 
of sodium citrate has recently been shown by Bosworth (see 
chapter on Chemistry of Cow's Milk) to be dependent in large 
part on reactions that occur in the milk itself. It changes the 
compound known as calcium caseinate into sodium caseinate. 
Sodium caseinate is changed by rennin to sodium paracaseinate, 

1 Sieber: Nad. Jour. f. prakt. Chemie, 1879, xix, 433. 

2 Cohn, F. O.: Zeitschr. f. Phys. Chem., 1890, xiv, 75. 

3 Hirschfield: Pfluger Arch., 1890, xlvii, 510. 

4 Hahn: Am. Jour. Dis. Ch., 1914, vii, 305. 

5 Southworth: Arch, of Pediatrics, Feb., 1905, p. 131. 

6 Clark: loc. cit. 



PHYSIOLOGY OF DIGESTION 



13 



which is soluble, while calcium paracaseinate, which is formed 
from calcium casemate, is insoluble. Coagulation by rennin is 
thus prevented. To what extent sodium citrate may also com- 
bine with the hydrochloric acid of the stomach to form sodium 
citrate, and thus reduce the amount of "available hydrochloric 
acid," is unknown. 

Rennin: (Chymosin). — The rennin ferment has been found in 
the stomach on the first day of life. 1 It causes the coagulation 
of milk. It is in the form of a pro-ferment in the gastric mucous 
membrane, which is inactive until it has come into contact with 
hydrochloric acid. 2 According to Hahn 3 it works best with a 
hydrogen-ion concentration (H) = 1.0 X 10 ~ 5 . Some writers, 4,5 
believe that rennin and pepsin are identical, because it has been 
impossible to separate the two enzymes by obtaining specific anti- 
bodies for them. There is not sufficient evidence available to 
settle this question. 

Pepsin. — Pepsin has been extracted from the gastric mucous 
membrane of a four months' old fetus 6 and is usually present at 
all ages in both health and disease. 7 Healthy breast-fed infants 
seem to produce less than healthy artificially-fed infants of the 
same age. The amount increases from birth until the end of the 
third month of life, after which it remains constant. Older babies 
of less than the normal weight produce the amount of pepsin which 
corresponds to their ages. 8 The stomachs of babies with severe 
chronic disturbances of nutrition frequently contain no pepsin. 
When these babies improve in health and gain in weight, their 
stomachs again contain pepsin. The stomach juice of normal in- 
fants is capable of transforming protein into peptone. 9, 10 Pepsin 
is present in the gastric glands as pepsinogen (Glassner), which 
is converted by hydrochloric acid into pepsin. An hydrochloric 
acid extract of the gastric mucous membrane quickly loses its 
power of peptonization when the acid is neutralized with soda. 

Absorption in the Stomach. — Most of the direct experiments 
on gastric absorption have been done on animals and indirect 

1 Sz-dlowski: Jahrb. f. Kinderh., 1892, xxxiv, 411. 

2 Glaessner: Beitr. z. chem. Physiol, u. Path., 1902, i, 24. 

3 Hahn: Am. Jour. Diseases of Children, 1914, vii, 305. 

4 Pawlow and Parastschuk: Zeitschr. f. Physiol. Chemie, 1904, xlii, 415. 

8 Blum and Boehme: Hofm. Beitr. z. chem. Physiol, u. Path., 1907, ix, 74. 

• Langendorff : Arch. f. Anat. u. Physiol., 1879, 95. 

7 Clark: loc. cit. 

8 Rosenstern: Berliner klin. Woch., 1908, xlv, 542. 

• Ramsey: Arch. Ped., May, 1909, 341. 

10 Langstein: Jahr. f. Kinderh., 1906, Neue Folge, lxiv, 139. 



14 PHYSIOLOGY OF DIGESTION 

methods have to be depended upon in babies. Pfannenstill 1 
found that iodine appeared in the urine of healthy breast-fed babies 
in from fifteen to twenty-five minutes after it was given by mouth. 
These results have been confirmed by other observers. Gundobin 2 
found that the absorptive power of the stomach (for KI) was 
diminished in disease in direct proportion to the severity of the 
disease. For example, in "dyspepsia" potassium iodide was ab- 
sorbed on the average in 17.1 minutes, in "gastroenteritis" in 24.5 
minutes, and in "cholera infantum" in 34.9 minutes. According 
to Cannon 3 absorption is an associated function of the churning 
action in the vestibule of the stomach. "Although water is not 
absorbed in the stomach, glucose in concentrated solution, and 
proteins which have been expossed to gastric digestion, may be 
absorbed in considerable amount (V. Mering and Tobler). The 
mucosa of the vestibule has fewer glands than the muscosa of the 
cardiac end, where they are placed in very close order. The 
absorption that occurs in the stomach probably takes place, there- 
fore, in the vestibule, for there the epithelial surface is most favor- 
able to the process. There also gastric digestion is most advanced, 
and the food in consequence is most ready for passage through the 
mucosa. Furthermore, the mechanical conditions in the vestibule 
are most favorable to absorption because the digested food is re- 
peatedly brought into very close contact with the mucous lining." 

PANCREAS 

The weight of the pancreas increases in general parallel with 
the body weight. Taking average figures, the increase of weight 
in intra-uterine life is relatively rapid, so that it is forty times 
larger at birth than it is at the third month of fetal life. After 
birth it doubles in weight in from three to four months, at the 
same time increasing its functional activity proportionately. The 
increase in weight from this time on is slower. 

The table of Hartge 4 on page 15 (Table 5) gives the weights 
and measurements of the pancreas: 

The pancreatic secretions contain three digestive ferments, 
namely, trypsin which splits up protein, amylopsin which changes 
starch into sugar, and steapsin which splits neutral fat into fatty 

1 Pfannenstill: Nord. med. Archiv., 1892, Neue Folge, ii, Heft 10. 

2 Gundobin : Die Besonderheiten des Kindesalters, Berlin, 1912, 272. 

3 Cannon: The Mechanical Factors of Digestion, New York and London, 
1911, 68. 

4 Hartge: The Pancreas of the Foetus and Newborn: Diss. St. Petersburg, 
1900 (Russian), quoted by Gundobin. 



PHYSIOLOGY OF DIGESTION 



15 



acids and glycerin. All these ferments are probably present in 
the pancreas of the human fetus from the third month of fetal life 
onward. At birth the amount of trypsin and steapsin is less than 
in the adult, and amylopsin is always found during the first week 
of life and increases in amount with the age of the infant. 1, 2 * 3> 4 
In chronic diseases such as congenital syphilis and "enterocolitis" 
there may be an interstitial pancreatitis with a corresponding 

TABLE 5 



Age 


Number of 


Wt. in 


Average 

length in 

cm. 


Width in 


Thickness in 


cases 


grammes 


cm. 


cm. 


3 mos. fetus 


1 


0.07 


1.1 


0.4 -0.2 




4 " " 


2 


0.145 


1.65 


0.75-0.27 


0.33-0.17 


5 " " 


3 


0.38 


3.2 


0.8 -0.5 


0.34-0.21 


6 " " 


6 


0.38 


3.2 


0.8 -0.48 


0.38-0.25 


ij (i a 


2 


0.76 


4.35 


1.0 -0.63, 


0.4 -0.25 


8 " " 


2 


1.18 


4.32 


1.2 -0.7 


0.6 -0.35 


9 " " 


4 


1.63 


5.7 


1.5 -0.85 


0.58-0.35 


1-2 months 


3 


2.61 


6.93 


1.6 -0.9 


0.66-0.56 


2-3 


3 


2.64 


7.54 


1.6 -0.9 


0.65-0.5 


3-4 


3 


4.93 


7.46 


2.1 -1.5 


0.8 -0.57 


4-5 


3 


5.4 


7.5 


2.25-1.5 


0.85-0.8 


5-6 


3 


5.28 


7.0 


1.75-1.25 


0.95-0.65 


6-9 


3 


7.37 


8.2 


2.0 -1.6 


1.0 -0.65 


9-12 " 


3 


8.67 


9.5 


2.0 -1.2 


0.9 -0.45 



weakening of the pancreatic ferments (Gundobin). Hess 5 
shown that lipase (steapsin) may be deficient in acute intestinal 
indigestion while the two other pancreatic ferments are present 
in considerable amounts. 

The secretin of the intestinal mucous membrane stimulates the 
production of the pancreatic ferments. Bayliss and Starling 6 
showed that when inorganic or organic acids were discharged from 
the stomach into the duodenum secretin was set free. When se- 
cretin is carried by the blood to the pancreas it starts the pan- 
creatic secretion. Secretin has been found in the fetus and in 
many new-born babies. The peptic ferment, trypsin, is present 

1 Hess: Am. Jour. Dis. Children, 1912, ii, 205, Summary of Literature. 

2 Moro: Jahrb. f. Kinderh., 1898, xlvii, 342. 

3 Ibrahim and Gross: Ref. Deut. med. Wochenschr. Vereinsbeilage, 1908, 
xxv, 1128. 

4 Hartge: loc. tit. 

5 Hess: Am. Jour. Dis. Children, 1913, v, 268. 

a Bayiiss and Starling: Jour. Physiol., 1902, xxviii, 325-53, 1903, 174. 



16 PHYSIOLOGY OF DIGESTION 

in the pancreas as the pro-ferment tripsinogen. Many fetuses 
have trypsinogen, but no trypsin. The secretion of enterokinase 
is called forth by the pancreatic juice and has been demonstrated 
in new-born and premature babies by Ibrahim. The pancreatic 
ferments, with the added action of erepsin, carry the digestion of 
proteins from albumoses and peptones into amino acids. 

The fat-splitting ferment, called lipase or steapsin, is active in 
acid, alkali, or neutral surroundings. This ferment is present in 
the pancreatic juice in part as a pro-enzyme, which is changed by 
the bile into steapsin. The bile in this way increases the fat- 
splitting power of the pancreatic ferments * and facilitates emul- 
sion. 

There is no work upon the sugar-splitting ferments in babies 
other than that of Ibrahim, 2 Miura, 3 neither of whom are able 
to find any in the new-born. 

LIVER 

The weight of the liver post-mortem depends upon whether or 
not it is full of blood. When the former weight is taken, it is 
known as the " physiological weight," and the latter as the " post- 
mortem weight." The physiological weight is obtained by filling 
the fiver to its maximum with water, after it has been removed 
from the body. 

The following table of Kowalski's 4 gives the weights of the 
livers of fifty normal infants: 

1 Furth and Schutz: Hofm. Beit. z. chem. Physiol, u. Path., 1907, ix, 28. 

2 Ibrahim: Verhandl. d. Gesell. fur Kinderh. Koln., 1908, 21. 

3 Miura: Zeitschr. f. Biologie. 32 Neue Folge, 1895, xiv, 266. 
4 Kowalski: Die Leber des Kindes. Diss. St. Petersburg, 1900 (Russian), 

quoted by Gundobin. 



PHYSIOLOGY OF DIGESTION 



17 





TABLE 6 








Total wt. of liver 


Body weight in 


Age 


No. of cases 


in gram 


gram 


5 mos. fetus 


1 


39 


650 


-J tc a 


1 


70 


1,320 


SH " " 


1 


110 


2,000 


9 " " female 


1 


100 


1,900 


9 " " male 


2 


92 


2,000 


New-born 


3 


130 


3,000 


1-7 days 


4 


133.5 


3,150 


2-3 mos. 


6 


187.5 


4,075 


3-4 " 


4 


259 


4,350 


4-5 " 


2 


248 


5,900 


8-10 " 


2 


320 


7,000 


15 " 


2 


325 


10,000 



The weight of the liver in comparison with that of the body is 
4.33% in the new-born and 2.85% in the adult. The function of 
the liver is to manufacture bile and to change carbohydrates, 
proteins and fats into glycogen. 1 Its cells also play an important 
part in the formation of urea. 

Bile. — The composition of bile, according to Geptner, 2 is as 
follows : 

TABLE 7 



Age 


Amount 


Composition of the bile 






Water 


Solids 


Mucin 


Bile 

salts 


Sodium 
glyco- 
cholic 
acid 


Sodium 
tauro- 
cholic 
acid 


Choles- 
terin, 

Fat, Le- 
cithin 


Mineral 
salts 




Per cent 


93.54 


6.46 


1.56 


2.35 


1.40 


0.90 


1.86 


0.53 


Infants 


of 100 parts 
of dry sub- 
stance 




100 


25.23 


35.09 


21.22 


13.11 


28.44 


8.08 




Per cent 


91.87 


8.13 


1.54 


3.32 


2.21 


1.06 


2.26 


0.86 


12-18 

months 


of 100 parts 
of dry sub- 
stance 




100 


19.13 


40.88 


27.11 


13.16 


27.18 


10.89 




Per cent 


87.61 


12.37 


1.98 


6.38 


3.49 


1.57 


1.99 


0.82 


Adults 


of 100 parts 
of dry sub- 
stance 




100 


16.0 


51.57 


28.21 


12.69 


16.09 


6.62 



x Kowalski: loc. cit. 

2 Geptner: Die Chemische Zusammensetzung der Galle des Kindes. Diss. 
St. Petersburg, 1900 (Russian), quoted by Gundobin. 



18 



PHYSIOLOGY OF DIGESTION 



The bile salts are of importance in activating the pancreatic 
juices and in acting with them in splitting the fat. The liver, be- 
sides secreting the bile, acts as a protection against bacterial and 
other poisons. 1 

INTESTINES 

The length of the intestinal tract increases fairly regularly with 
the age of the infant. 

The table on this page is the result of measurements by Debele: 2 
Small Intestine. — The juices of the small intestine contain in- 
vertin (Ibrahim), both in the fetus and in the new-born. Several 
writers, 3 ' 4> 5 have demonstrated erepsin in the fetus and other 
ferments have been identified by other writers. Lang and Fenger, 6 
studied the reaction of the small intestine in animals and man, 
employing an electrometric method. An alkaline reaction is less 
common than an acid one, even close to the duodenum, where a 



TABLE 8 







Length of trunk 










from the 7th 


Length of the 


Length of the 


Age 


Number of 


cervical vertebra 


small intestine 


large intestine 




cases 


to the coccyx 
in cm. 


in cm. 


in cm. 


1 month 


4 


21.5 


296.4 


63.3 


1-2 mos. 


6 


21.1 


319.1 


65.1 


2-3 " 


14 


22.2 


358.1 


70.6 


3-4 " 


5 


23.1 


379.4 


71.2 


4^5 " 


4 


25.5 


383.4 


72.3 


5-6 " 


5 


25.1 


380.3 


69.2 


7-9 " 


2 


27.0 


412.4 


80.5 


6-12 " 


6 


27.0 


419.8 


83.9 


Average 


46 


23.5 


365.3 


71.6 



temporary alkalinity may be established by bile. The usual reac- 
tion is between 1 to 3 X 10 " 7 . 



1 Uffenheimer: Ergebnisse d. inn. Med. et Kinderh., 1908, No. 2, 271. 

2 Debele: Die Lange des Darmkanals im Kindesalter. Diss. St. Petersburg, 
1900 (Russian), quoted by Gundobin. 

3 Langstein and Soldin: Jahrb. f. Kinderh., 1908, Neue Folge, lxvii, 9. 

4 Jaeggy: Zentralblatt f. Gynak., 1907, No. 35, 1060. 
6 Foa: Munch, med. Wochenschr., 1907, 2201. 

6 Science, 1917, xlvi, p. 000. 



PHYSIOLOGY OF DIGESTION 19 

Carbohydrates are split into monosaccharides in the small intes- 
tines, where they are absorbed. The specific ferments, invertin, 
lactase, and maltase, convert the corresponding sugars into mono- 
saccharides and are either present in the digestive juices or in the 
mucous membrane. Food stays a relatively short time in the 
small intestine, but during that time is mixed with and acted upon 
by the digestive juices so that it is ready for absorption before it 
reaches the large intestine. 

There is nothing definitely known about the secretions of the 
large intestine. 

Digestion-Leucocytosis. — The evidence on this point is con- 
flicting. Recent work shows that it is only present in 12% of the 
cases, while in the remainder there is no increase in the leucocytes 
after the ingestion of food but rather a decrease. The probable 
explanation being that they are drawn away from the peripheral 
circulation to the digestive tract. 



CHAPTER II 
THE DIGESTION AND METABOLISM OF FAT » 

The fat in the infant's food is principally in the form of neutral 
fat. Saliva has no action upon it, and, although saponification 
begins in the stomach, it probably is not carried on to a. point 
which influences to any degree the future digestion of the fat. The 
action of the fat-splitting ferment of the stomach is eventually 
stopped entirely by the acid reaction of the stomach contents. The 
action of the gastric secretions is of importance indirectly, because 
when milk is coagulated by rennin, most of the fat is ensnared in 
the meshes of the casein curds, and the casein coating must be 
first digested before the digestive juices can reach the fat. There 
is, therefore, very little opportunity for the absorption of fat in the 
stomach. This ensnaring of the fat by the casein may be of phys- 
iological importance in preventing the liberation of too large an 
amount of fat in the intestinal canal at one time. 

Fat has a definite influence on the emptying time of the stomach, 
large amounts tending to delay it. 2 Large amounts of fat in the 
food are, according to Tobler 3 of etiological significance in the 
pathogenesis of pyloric spasm. He found in the stomach of one 
infant more fat than had been given to it during the previous 
twenty-four hours. He also calculated that one liter of milk would 
cause one and a half liters of digestive juices to be secreted. 

The real digestion of fat commences when it reaches the small 
intestines, where it undergoes a physical change. The fat is 
first of all subdivided by the alkaline salts of the bile, and of the 
pancreatic and intestinal juices. Fatty acids, which are formed 
as the result of the action of the fat-splitting ferments, react with 
the alkaline carbonates present to form soaps. The soaps which 
result make the fat particles still smaller and form an emulsion. 

Absorption. — There is considerable evidence to show that neu- 
tral fat (unsplit fat), is not absorbed as such into the intestinal 

1 Tobler and Bessau: Allegemeine Pathologische Physiologie der Ernahrung 
und des Stoffwechsels im Kindesalter, Wiesbaden, 1914, has been consulted 
and quoted freely in this section. 

2 Tobler and Bogen: Monatsschr. f. Kinderh., vii, 12. 
'Tobler: Verhandl. d. Gesellschaft f. Kinderh., 1907, 411. 

20 



DIGESTION OF FAT 



21 



wall: for example, hydrous wool fat and paraffin, which may be 
made into emulsions but cannot be split, are not absorbed. 1 It 
has also been shown by animal experimentation that the amount 
of fat in the chyme is directly proportional to the amount of fat 
which has been split. 2 It is also taught by some that fat is ab- 
sorbed both in the form of an emulsion and in the form of water- 
soluble soaps, neither view excluding the other. Langworthy and 
Holmes, 3 studied the digestibility of fat in the adult and found 
that its " coefficient of digestibility " was dependent on its melt- 
ing point; the lower the melting point the greater the digesti- 
bility. This is shown in the following table: 



Fat studied 


Coefficient of 
digestibility 

% 


Melting point 
degrees C. 


Butter fat 
Lard 
Beef fat 
Mutton fat 


97 
97 
93 
88 


32 
35 
45 
50 



Bloor 4 found that substances similar to food fat in that they 
emulsified well, were soluble in fat solvents and were liquid at 
temperatures below that of the body, but could not be converted 
into a water soluble form, and were not absorbed at all in the intes- 
tinal canal. He concluded that the slow passage of fats from the 
stomach, the abundant provisions for hydrolysis and for the ab- 
sorption of fat-like substances which can be changed to a water 
soluble form, make it extremely probable that saponification is a 
necessary preliminary to absorption. The significance of the mech- 
anism involved is little understood, but one of its uses would 
appear to be to exclude undesirable fat-like substances which 
would otherwise be carried into the body with the fats. 

Kastle and Loevenhart 5 demonstrated the almost universal pres- 
ence of lipase in the tissues, and showed that this ferment could 
reverse its action. That is to say, it can synthetize or change 
soaps back into neutral fats as well as split neutral fats and form 
soaps. It is, therefore, possible that the soaps, which have been 

1 Connstein, W. : Arch, f . Anat. u. Physiol., 1899, 30; Henriques and Han- 
sen: Zentralblt. f. Physiol., 1900, xiv, 313. 

2 Levites: Ztschr. f. physiol. Chem., xlix, 273; liii, 349. 

3 Bull. 136, Expt. Sta. U. S. Dep't Agric., 1903, p. 113. 

4 Bloor: Jour. Biol. Chem., xv, 105, and Jour. Biol. Chem., 1914, xvi, 517. 
6 Kastle and Loevenhart: Am. Chem. Jour., 1900, xxiv, 491. 



22 DIGESTION OF FAT 

formed during the digestion, are changed during their passage 
through the intestinal epithelium by the reversible action of lipase 
into neutral fat, because neutral fat is found almost exclusively 
in the lymph stream. Whitehead's l experiments on cats seem to 
strengthen this statement because, he found that butter-fat stained 
with Sudan III lost the stain during absorption (soaps will not 
stain with Sudan III); Sudan-staining fat was seen in the lumen 
of the intestine; none was seen in the intestinal epithelium and a 
Sudan-staining fat was again found in the lacteals of the villi. 
The weight of evidence, therefore, is that fat must be converted 
into a water soluble form, soap, before it can be absorbed. The 
fate of glycerin, the other end product of fat-splitting is un- 
known. 

Noll 2 and Wilson 3 conclude from their studies with animals 
that the epithelium of the intestinal mucous membrane plays a 
part in the absorption of fat. The emulsified fat is taken up into 
the striated cells bordering the villi. These cells contain a con- 
siderable amount of fat before the fat can be detected in the lac- 
teals. A stage is then reached in which the fat content of the mu- 
cosa further increases and at the same time removal through the 
lacteals sets in. The fat is then found in the lacteals until all the 
fat has been removed from the epithelial cells. There is hardly any 
evidence to show that the fat can be carried from the epithelial 
cells to the lacteals by leucocytes. Samelson 4 has found a fat- 
splitting enzyme in the blood of infants. 

About two-thirds of the fat in the food enters the thoracic duct 
as chyle and may be accounted for in this way. The fate of the 
other third is not clear. It may find its way to the liver by way of 
the intestinal capillaries. The subsequent course and fate of fat 
was unknown until Bloor 5 added new light to the subject. He 
found that lecithin in the blood increased during the absorption 
of fats. This increase was mostly in the blood corpuscles and 
very little in the plasma. The fatty acids increased in both 
plasma and corpuscles, but to a greater extent in the latter; 
while cholesterol showed no change during digestion. Bloor con- 
cludes that the close connection between the fatty acids and 
lecithin can be interpreted to mean that all absorbed fat passes 
through the lecithin stage. 

1 Whitehead: Am. Jour. Physiol., 1909, xxiv, 294. 

2 Noll: Arch. ges. Physiol., cxxxvi, 208. 

3 Wilson: Trans. Canadian Inst. Sept., 1906, viii, 241. 

4 Samelson: Zeitschr. f. Kinderh., 1912, iv, 205. 
6 Jour. Biol. Chem., 1916, xxiv, 447. 



DIGESTION OF FAT 23 

When the fat has entered the blood stream it can be demon- 
strated by the ultra microscope. When fat is present in the blood 
after food has been taken, the condition is called digestion lipemia. 
It commences two to three hours after meals and disappears after 
seven to eight hours. 1 The height of the curve is dependent on the 
amount of fat in the food, and also on the age and condition of the 
infant. 

The absorption of fat is extraordinarily good in health in babies 
fed on cow's milk as well as in those fed on human milk. It is 
usually over 90% and may be as high as 98% of the fat ingested; 2 
8% to 11% of the ingested fat is absorbed in the upper part 
of the small intestine 3 and the absorption of fat is nearly com- 
plete at the ileocecal valve. 3 The large intestine is capable of ab- 
sorbing fat in large amounts under special favorable conditions, 4 
but under ordinary circumstances absorption here is probably 
very slight. 

The results of estimations of the amount of fat in the stools 
of babies in starvation and in health make it probable that the 
greater part of the fecal fat comes from the food and not from the 
intestinal secretions. 5 It is evident, therefore, that the study of 
the fat in the stools with the microscope will give valuable infor- 
mation about the digestion. It is necessary first to know how much 
fat may normally be found in a stool. There is a comparatively 
large amount of fat present in the first days of life, and this amount 
gradually becomes less as the babies grow older, 6 decreasing from 
50% of the dried stools to between 14 and 25%. There is so 
much fat passed in the stools during the early weeks that it is 
practically impossible to ascertain by simple microscopic ex- 
amination whether there is an excess or not. In later infancy 
less fat is present and, therefore, microscopic examinations are 
of more value. In normal and in many pathologic conditions the 
greater part of the fat, 75% or more, is in the form of fatty acids 
and soaps. 

1 Neumann: Wien, klin. Wochenschr., 1907, 851; Schelble: Miinchen med. 
Wochenschr., 1908, No. 10, p. 492; Bahrdt: Breslauer Tagung der Freien Ver- 
einigung fur wissenschaftliche Padiatrie, 1908; Monatschr. f. Kinderh., vii, 
106. ■ 

2 Czerny and Keller: "Des Kindes Ernahrung, Ernahrungstorungen und 
Ernahrungstherapie," Leipzig u. Wien, 1906, I, 263; Freund: Ergebn. d. inn. 
Med. u. Kinderh., 1909, iii, 139. 

3 Levites: loc. tit. 

4 Hamburger, H. J.: Engelmann's Arch., 1900, 433. 

6 Czerny and Keller: loc. tit. 

6 Talbot, F. B.: Boston Med. and Surg. Jour., 1909, vol. clx, No. 1, 13. 



24 METABOLISM OF FAT 



METABOLISM 

Methods. — Most of the earlier figures of the metabolism of fat 
were obtained by the Rosenfeld extraction method, 1 or one of its 
modifications. Later Kumagawa and Suto 2 criticised these meth- 
ods and devised a saponification method which goes under their 
name. These two methods are the ones most commonly used on 
the continent. The Folin- Went worth method 3 (extraction) is 
now used in America almost to the exclusion of the other two 
methods. Gephart and Csonka 4 have recently shown the pres- 
ence of errors in all of the above methods and have described a 
method by which they have endeavored to overcome these errors. 5 
Up to date there are no metabolism figures in infancy which were 
obtained by this method. When the methods are studied, it be- 
comes obvious that figures obtained by one method cannot fairly 
be compared with those obtained by another method, because they 
probably do not represent the same things. It is obvious also 
that slight differences in figures are of no significance and that only 
the most striking differences are of practical importance. Un- 
fortunately, the clinical status of the infant is not sufficiently con- 
trolled and recorded in most instances and the possibilities of 
error, both from errors in chemical technique, and in clinical ob- 
servation, are numerous. Despite these facts, it seems wise to 
summarize what we think we know about the digestion and ab- 
sorption of fat in health and disease. 

Fat Excretion on Fat-free Food. — A careful analysis of the 
figures that are at present available shows that even when the 
quantity of fat in the food is very minute, an ether soluble sub- 
stance, which is recorded by investigators as fat, is found in the 
stools. In most instances in infants the amount of this substance 
is smaller than the amount of fat in the food, and if it is fat it 
might very well originate in the food. 6 On the other hand, since 
fasting adults have had small quantities of fat in the stools, it is 
argued that this fat must come from the body. The amount of 

1 Rosenfeld: Centralb. f. inn. Med., 1900, xxi, 833. 

2 Kumagawa and Suto: Biochem. Zeitschr., 1908, viii, 212. 

3 Folin and Wentworth: Jour. Biol. Chem., June, 1909-10, vii, 421. 

4 Gephart and Csonka: Jour. Biol. Chem., Dec, 1914. 

5 A Rapid Nephelometric Method for the Determination of Fat in the 
Stools has been recently described by Laws and Bloor: Am. Jour. Dis. Chil- 
dren, 1916, xi, 229. 

6 See expts. of Aschenheim (Kumagawa and Suto method), Jahrb. f. Kin- 
derh., 1913, lxxvii, 505. 



METABOLISM OF FAT 25 

fat in question is so small that the discussion is of more theoretical 
than practical importance. 

Fat Absorption in Health. — It is generally agreed that the fat 
absorption of healthy infants is very high both in the breast-fed 
and in the artificially fed. Uffelmann * found that a breast-fed 
infant absorbed approximately 97.8% of the fat ingested. Shaw 
and Gilday 2 found the absorption 96%, while Nob^court and 
Merklen 3 found the absorption of fat respectively 98.3, 99.7, 
98.27, 98.23, and 98.62% in five healthy breast-fed infants. Fur- 
ther figures are given by Czerny and Kellar. 4 

The absorption of fat in normal artificially-fed babies is also 
extraordinarily good and, according to Freund, it may remain ab- 
solutely normal even under abnormal conditions of nutrition. He 
records instances with "soap stools" in which the fat absorption 
reached as high as 97% of the intake (see Czerny and Kellar, 5 and 
Freund). 6 Freund gives 91.86% to 98.98% as the figures for the 
absorption of fat for healthy, breast-fed infants. The figures are 
somewhat lower in the babies he calls "apparently normal," but 
analyses of these figures show that these babies are considerably 
under the average weight for their age and can, therefore, not 
be considered "average normal." Nevertheless many of these 
infants show a very good absorption of fat. 

The significance of fatty acids and soaps is as yet unknown. 
Freund 7 has shown that an acid dyspeptic stool can be changed 
in many instances to a formed "soap stool" by a relative increase 
in the amount of casein, while an alkaline soap stool can be changed 
into an acid stool by a relative increase in the amount of carbohy- 
drates. Coincident with the change from an acid to an alkaline 
stool there is a change of the intestinal flora. Bahrdt 7 in contradis- 
tinction to Freund (see p. 22) has recently shown that babies passing 
"soap stools" may have diminished powers of absorption and that 
they may lose more than was formerly taught. He found the 
absorption of fat (Kumagawa and Suto method) as follows: 

Uffelmann: quoted by Tobler and Bessau, loc. cit. 

2 Shaw and Gilday: Brit. Med. Jour., 1906, ii, 932. 

3 Nobe*court and Merklen: Rev. mens d. Mai. de l'enfance, 1904, xxii, 337. 

4 Czerny and Kellar: loc. cit. 

6 Freund: Ergeb. d. inn. Med. u. Kinderh., 1909, iii, 158-159. 
Freund: loc. cit. 

'Bahrdt, H.: Jahrb. f. Kinderh., 1910, lxxi, 249; Holt, Courtney & Fales: 
Am. Jour. Dis. Children, 1915, ix, 533. 



26 



METABOLISM OF FAT 



TABLE 9 



Name of baby 


Age, 
months 


Body 

Weight, 

gm. 


Fat ab- 
sorbed, 
per cent 


Character of 
stools 


Schroder, 7 days 

Schuler, 7 days 

Weiss la, 5 days 

Weiss, lb 


9 

2 

9/io 

9/io 

10 


7470 
3945 
3750 
3750 

3900 


82.4 
83.2 
81.9 
86.0 

93.0 


"Soap stools" 
Mostly "soap stools" 
"Soap stools" 
"Soap stools" 

Normal stools 


Weiss II, 8 days 
(Breast and skim milk) 



The fat absorption in these babies with "soap stools" is, there- 
fore, considerably less than that of normal infants. There is, how- 
ever, not such a loss of fat as in diarrhea. The formation of "soap 
stools" may be prevented by the addition of whey to the diet. 1 

It is very difficult to determine in the cases that have not been 
previously investigated how much their powers of digestion had 
been injured by previous poor feeding or disease. Conclusions 
as to the effect of the food on sick babies, on this account, must be 
very conservative. There seems to be little doubt, however, that 
increased peristalsis results in an increased loss of fat in the stools. 
Certain phases of this question will be considered in more detail 
later. Increased loss of fat in the stools may occur in any diarrhea, 
whether it be due for example, to an acute infection, or to chilling, 
or to an excess of sugar in the food. Birk's observations on Groe- 
ger III, during a period in which the temperature was elevated 
and there were frequent thin stools, showed an absorption of only 
79%. Courtney 2 says that the lowest absorption in her cases, 
Janes 52.3% and Stoker 34.2%, was the result of increased peristal- 
sis and diarrhea. Usuki 3 found that when large amounts of malt 
extract were added to the food of an infant with alkaline stools 
the loss of fat in the stools increased from 10% to 15%. The 
same results were recorded for lactose by Talbot and Hill, 4 who 
found in their case that the absorption of fat while the digestion 
was good was 90% and that during a "sugar diarrhea" it dropped 
to 75%. 

The percentage of fat in the dried stool is higher in parenteral 
febrile infections than in health. Uffelmann 5 found, for example, 

1 Giffhorn: Jahrb. f. Kinderh., 1913, Ixxviii, 531. 

2 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 
'Usuki: Jahrb. f. Kinderh., 1910, lxxii, 18. 

4 Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218. 

5 Uffelmann: quoted by Tobler and Bessau, he. cU. 



METABOLISM OF FAT 27 

that in an eight months' old infant with acute bronchitis and fever 
the fat excretion in the stools was as follows: 

TABLE 10 

Fat 

4th day 40.7% of dried stool 

7th day 37.8% of dried stool 

9th day 25.0% of dried stool 

13th day 15.2% of dried stool 

Fat Diarrhea. — Demme l and Biedert 2 described a condition 
which they called a fat diarrhea which was characterized by 
frequent, acid, diarrheal stools. Tobler thinks that, on account 
of their acidity, these stools are not characteristic of a primary 
fat indigestion, but that they may be secondary to some other 
form of indigestion which causes rapid peristalsis. He cites, as evi- 
dence in favor of this point of view, the fact that such a diarrhea 
will stop when the food is changed to "Eiweissmilch," even though 
the percentage of fat remains the same. It is a fact, nevertheless, 
that in certain instances, in which very large amounts of fat have 
been fed to young infants, they have passed three or four stools 
daily of the yellow color of Indian meal and the consistency of 
mush. Careful inspection of such stools shows drops of oil on the 
surface of and intermixed with the stool, while the microscope 
shows that the stool is composed almost entirely of fat. When 
the amount of fat is reduced in these cases without any other 
change in the food, the digestion becomes normal. Such cases 
are true fat diarrheas. 

Whether the fat in the stool is in the form of fatty acids or soaps 
depends chiefly upon the reaction of the stool, which in its turn 
depends upon the relation of the food components to each other. 
Talbot 3 has shown that "soft curds" or fatty curds, when al- 
kaline to litmus paper, are composed principally of soaps and, 
when acid to litmus paper, principally of fatty acids. 

The presence of a large amount of soaps presumably affects the 
absorption of the various salts. The technical difficulties in deter- 
mining the amount of calcium and other salts in the stools, make 
nearly all the figures very unreliable. 4 The usual conclusions 
from metabolism experiments are that in the normal infant, with 

1 Demme: Jahrb. iiber die Thatigkeit des Jennerschen Kinderspitals in 
Berlin, 1874 and 1877; quoted by Hecht, Die Faeces des Sauglings, etc., p. 128. 

2 Biedert: Jahrb. f. Kinderh., 1879, xiv, 336; ibid., 1888, xxviii, 21. 

3 Talbot: Boston Med. and Surg. Jour., 1909, clx, 13. 

4 According to Prof. Folin only those figures of the calcium metabolism 
obtained by McCrudden's methods are of any value. 



28 METABOLISM OF FAT 

a normal fat absorption, a high fat intake does not change the 
mineral composition cf the stools, while in chronic malnutrition 
the output of salts in the feces is considerably raised by increasing 
the fat in the diet. 1 

Olive oil is considered by some authors to have a beneficial ac- 
tion on the absorption of fat. The metabolism experiments of 
Courtney 2 and Freund 3 apparently bear out this belief. 

Infantile Atrophy. — "Alimentary decomposition" of Finkel- 
stein — ("Marasmus"). When the literature of the metabolism of 
"infantile atrophy" is studied the first questions which arise in 
the student's mind are what is the clinical picture of "infantile 
atrophy," and are all the cases reported under that name suffering 
from the same disease. The summaries of the clinical histories 
are so meager that it is impossible to draw any definite conclusions 
from them and the statement of the investigator as to the clinical 
status of the given infant has to be accepted. This state of affairs 
is, of course, unfortunate, but with the present disagreement 
among authorities as to what the disease really is, it cannot be 
remedied. With modern improvements in the methods of di- 
agnosis it is possible to separate out chronic tuberculosis and 
hereditary syphilis as definite clinical entities. Prematurity should 
also be set aside by itself. This leaves, to be classed as "infantile 
atrophy," those cases which correspond to Holt's 4 definition, that 
"infantile atrophy is the extreme form of malnutrition seen in 
infancy, occurring so far as is known, without constitutional 
or local organic disease. It is a vice of nutrition only." There 
must be many stages of the disease if there is such a clinical entity. 
These facts must be borne in mind in considering the subse- 
quent remarks. 

The fat content of the body of an atrophic infant as compared 
with the normal is very much diminished. Ohlmuller 5 found that 
the body of an atrophic infant contained only 3% fat as com- 
pared to 21% in a normal infant. Steinitz 6 analyzed the bodies 
of three atrophic infants, weighing 3190, 2625 and 1960 grams, and 
found that the total amount of fat was respectively 63.6, 37.9 and 
35.9 grams, or from 1.45 to 1.99% of the total mass, as compared 
with from 12.3% to 13.1% in the normal. 

1 Freund: Ergeb. d. inn. Med. u. Kinderh., 1909, iii, 139. 

2 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 

3 Freund: Biochem. Zeitschr., 1909, xvi, 453. 

4 Holt: Dis. of Infancy and Childhood, N. Y. and London, 1911, p. 227. 
6 Ohlmuller: Zeitschr. f. Biol. 1882, xviii, 78. 

•Steinitz: Jahrb. f. Kinderh., 1904, lix, 447. 



METABOLISM OF FAT 29 

A fatty liver is occasionally found at post-mortem examination, 
but, according to Holt, — "This lesion is not more frequent in this 
condition than in infants dying of other diseases." Hayaslei 1 
recently showed that in five out of eight cases of "infantile at- 
rophy" the liver contained neither fat nor lipoid substances. In 
two cases the livers were fatty. 

According to many authors 2 the digestive ferments are more 
or less diminished and weakened in infantile atrophy. This is 
especially true of the fat-splitting ferment. Hecht believes that 
there is a connection between the severity of the disturbance 
and the diminution in the amount of steapsin. Wentworth 3 
found that secretin was either diminished or absent in these 
cases. 

The metabolism of fat varies. Freund 4 found that two atrophic 
infants with "milchnahrschaden" (soft curds) absorbed respec- 
tively 90% and 97% of the fat, except in one instance when one 
absorbed only 81.8%. Bahrdt, 6 on the other hand, found an 
absorption of only 81.9, 82.4, 83.2, 86.0 and 93%. 

L. F. Meyer 6 studied "infantile atrophy" in different stages 
and with different foods. He found in baby Kajitzki in periods 
I and II, in which whole milk, diluted one-half, was given, that 
the absorption of fat was respectively 74.2% and 24.9%. In the 
first period there was a slight gain in weight, and in the second 
period a marked loss in weight, with a corresponding loss of fat 
in the stool. In periods III, IV, and V, the absorption of fat was 
respectively 51.0, 68.3, and 78.6%, and during the last period 
there was a gain in weight. Baby Bentler did not show the same 
loss of fat, but there was a greater retention of fat when human 
milk was given than when cow's milk was given. 

Fife and Veeder 7 studied two cases which they considered to 
be "infantile atrophy" and found that the fat absorption (Brugsch 
method for fat) was less than in normal infants. Curiously enough, 
the per cent of fat absorbed was larger when large amounts of 
fat were given than when small amounts were given. They did 
not find that the carbohydrates in the food had any influence on 
the fat absorption, but their evidence in this respect is incom- 
plete. 

1 Hayaslei: Monatschr. f. Kinderh., 1913, xii, 221. 
2 Tobler and Bessau: loc. cit. 130. 

3 Wentworth: Jour. Am. Med. Assoc, 1907, xlix, 204. 

4 Freund: Biochem. Zeitschr., 1909, xvi, 453. 

* Bahrdt: quoted by Tobler and Bessau, loc. cit. 

• Meyer, L. F.: Jahrb f. Kinderh., 1910, lxxi, 379. 

' Fife and Veeder: Am. Jour. Dis. Children, 1911, ii, 19. 



30 METABOLISM OF FAT 

Wentworth l studied the fat metabolism (Folin-Wentworth 
method), of an atrophic infant and found that its tolerance for the 
fat in human milk was much greater than for that of cow's milk. 
His results were confirmed in the case of Kajitzki. 2 He was un- 
able to determine whether this difference in the absorption of the 
two kinds of fat was due to a difference in the fats themselves or 
to some other ingredient in the milk. 

Hecht 3 and Reuss 4 have reported cases of congenital oblitera- 
tion of the bile duct with normal pancreas, in which only one-half 
of the fat was split. In Niemann's case 5 of an infant with ad- 
vanced biliary cirrhosis and congenital absence of the bile ducts, 
the nitrogen absorption was from 80% to 93% and the fat absorp- 
tion from 28% to 39%. In Koplik and Crohn's case 6 the nitrogen 
absorption was 86.2% and the fat absorption 48.4%. Very much 
less than the normal amount of fat was split. Similar types of 
stools with large amounts of unsaponified fat have been observed 
by us clinically. 7 These figures show that in the infant as well as 
in the adult, bile is necessary for the normal splitting and absorp- 
tion of fat. 

Tubercular peritonitis in babies is primarily a disease of the 
lymphatic system and when the mesenteric glands become caseous 
they form a dam beyond which the fat cannot pass. It has been 
shown earlier that most of the fat is normally carried by the lym- 
phatics to the blood stream. If this road is blocked with tuber- 
culous tissue, it is reasonable that some of the fat should be lost 
from the body. Talbot 8 studied cases with tuberculosis of the 
mesenteric glands and found that in all cases in which a large 
proportion of these glands were involved there was a loss of fat 
through the intestines. Hecht 9 believes that 8% of the fat in 
the stool should be split, and considers that great divergence from 
this amount means either trouble with the bile or pancreatic juice. 
He reports the case of a seven months, premature baby which was 
able to split only 53% of the fat, and considers this to be due to 

1 Wentworth: Boston Med. and Surg. Jour., 1910, clxii, 869, and Archives 
Int. Med., 1910, vi, 420. 

2 Meyer, L. F. : loc. cit. 

3 Hecht: "Die Faeces des Sauglings und des Kindes," Berlin- Wien, 1910, 
128. 

4 Reuss: Case of Obliterated Bile Duct (congenital) Reported in Discus- 
sion,— Jahrb. f. Kinderh., Dec, 1908, 729. 

5 Niemann: Zeitschr. f. Kinderh., 1912, iv, 152. 

8 Koplik and Crohn: Am. Jour. Dis. Children, 1913, v. 36. 

7 Morse, J. L. : Boston Med. and Surg. Jour., 1910, clxii, 238. 

8 Talbot: Am. Jour. Dis. Children, 1912, iv, 49. (See literature.) 
•Hecht: loc. cit. 



METABOLISM OF FAT 31 

weak action of the pancreatic fat-splitting enzyme, which pre- 
sumably is not completely developed. Finizio 1 explains a large 
amount of fat in the stool of an eleven months' old baby ill with 
mumps by probable trouble in the pancreas. In this case 75% 
of the dried stool was fat, and of this only 7% was soaps, while 
11% was fatty acid and 82% neutral fat. 

Czerny 2 believes that babies with an exudative diathesis can 
be harmed by fat. He finds that an increase in the amount of fat 
in the food will bring out eruptions on the skin. Steinitz and 
Weigert 3 have apparently proved the correctness of this assum- 
tion by a metabolism experiment. 

Towle and Talbot 4 studied the digestion of infants ill with ec- 
zema and found that in a large number of cases the severity of the 
skin eruption bore a direct relation to the fat in the food. This was 
by no means the case in all instances, but there was a sufficient 
number to substantiate Czerny's findings. 

There is no doubt that large amounts of fat can do a great deal 
of harm to most babies. Such babies come under two classes, — 
those which have a normal digestion and are unable to digest ex- 
cessive amounts of fat, and those which have diminished powers of 
digestion and are unable to digest normal amounts of fat. So 
much attention has been paid to the few babies that are unable to 
digest fat that we are apt to forget that most babies can digest fat 
within reasonable limits. L. F. Meyer 5 has shown in Finkel- 
stein's clinic that when fat is increased in the food of normal 
healthy babies there is no loss of fat or salts from the body. This 
dispels, in a very convincing way, the false impression that normal 
babies are unable to digest fat. Howland has shown in a recent 
investigation (not yet published) that a baby can be fed on large 
quantities of fat without symptoms of indigestion and without 
acidosis. 

finizio: Pediat. Sept., 1909, 674; Rev. in Archiv. f. Kinderh., 1910, liv, 
461. 

2 Czerny: Part I, Monatschr. f. Kinderh., 1906, iv, 1; ibid., Part II, 1908, 
vi, 1; ibid., Part 3, 1909, vii, 1. 

3 Steinitz and Weigert: Monatschr. f. Kinderh., 1910, ix, 385. 

4 Towle and Talbot: Am. Jour. Dis. Children, 1912, iv, 219. 

5 Meyer, L. F.: Jahrb. f. Kinderh., April, 1910, 379. 



CHAPTER III 

THE DIGESTION AND METABOLISM OF CARBO- 
HYDRATES 

FERMENTS 

Saliva. — Zweifel * found diastase in the parotid gland of the 
newly-born, but was unable to find it in the submaxillary. Ibra- 
him, 2 after prolonged investigations, found it in both the parotid 
and submaxillary glands, its action being stronger in the former 
than in the latter. Diastase was found much earlier in fetal life 
in the parotid than in the submaxillary, traces being found in 
the former at the fourth and in the latter at the sixth month of 
fetal life. The diastase of the parotid is the earliest digestive fer- 
ment found in the embryo. 

A diastatic ferment can always be found in the saliva of healthy 
infants. 3 The diastatic action of saliva may continue in the 
stomach as long as two hours after feeding. 4 

Stomach. — Ibrahim 5 is the only worker who has examined the 
gastric mucous membrane of the newly-born for the carbohydrate 
splitting ferments, and he has been unable to find either lactase, 
maltase or invertin. 

Pancreas. — Moro 6 was able to demonstrate the presence of an 
amylolytic ferment in the pancreas of newly-born babies when the 
pancreas was thoroughly extracted, and thus disproved the earlier 
work of Zweifel and Korowin. Ibrahim 7 never failed to get the 
ferment in a six months' fetus when he tested the action of the 

1 Zweifel: Untersuchungen iiber den Verdauungsapparat der Neugeborenen, 
Berlin, 1874. 

2 Ibrahim: Verhandl. d. Gesell. fur Kinderh., Koln, 1908, p. 21. 

3 Schiffer: Bed. klin. Wochenschr., 1872, ix, 353; Korowin: Jahrb. f. Kin- 
derh., 1875, viii, 381; Zweifel: loc. cit.; Schlossmann: Jahrb. f. Kinderh., 
1898, xlvii, 116; Montagne: Dissertation, Leyden, 1889, quoted in Czerny 
and Keller, — "Des Kindes Ernahrung," etc.; Schilling: Jahrb. f. Kinderh., 
1903, lviii, 518. 

4 Shaw: Albany Med. Ann., 1904, xxv, 148. 
6 Ibrahim: loc. cit. 

6 Moro: Jahrb. f. Kinderh., 1898, xlvii, 342. 

7 Ibrahim: loc. cit. 

32 



DIGESTION OF CARBOHYDRATES 33 

ferment on starch meal. He was, however, unable to find it when 
he tested soluble (i. e., cooked) starch. 

Ibrahim was unable to demonstrate invertin and lactase in the 
pancreas of newly-born or older babies, but he was usually able to 
demonstrate maltase in the newly-born and always in older chil- 
dren. Maltase may also be found in the blood. 

Small Intestine. — The mucous membrane of the small intes- 
tine contains amylolytic ferments. 

Lactase, the ferment which splits milk sugar, has been repeatedly 
found in the mucous membrane of the small intestine. 1 Ibrahim 
always found it in the small intestine and meconium of newly-born 
babies, but was unable to find it in premature infants. He says, 
however, that his method of determining lactase is not capable of 
demonstrating small amounts. Lactase is more abundant in young 
animals than in the adult. 

Pautz and Vogel found maltase, the ferment which splits malt 
sugar, in the small intestine of infants. 

Invertin, the ferment which splits cane sugar, was found in the 
secretions of the small intestine of the newly-born by Miura 2 and 
Ibrahim was always able to demonstrate its presence both in the 
intestinal mucous membrane and in the intestinal contents of all 
fetuses. 

Large Intestine. — It is difficult to wash the large intestine free 
from meconium, and the results of the examinations of its mucous 
membrane are variable, as the tables of Miura, Pautz and Vogel 
show. It is, therefore, impossible to say whether it contains fer- 
ments or not. 

Stools. — Pottevin 3 found an amylolytic ferment in the me- 
conium. Kerley, Mason and Craig 4 were able to demonstrate the 
presence of a strong amylolytic ferment in the stools of very young 
babies, the possibility of the bacterical fermentation of starch 
being excluded. There is a larger amount of diatase in the stools 
of breast-fed babies than in those of the bottle-fed, which Hecht 5 
believes to be due to the fact that the intestinal contents of the 
breat-fed baby pass more quickly through the intestinal canal 
than do those of the bottle-fed baby. The power of digesting 
starch, while occasionally absent is, therefore, almost always pres- 

1 Pautz and Vogel: Zeitschr. f. Biol., 1895, xxxii, 304; Weinland: ibid., 1899, 
xxxviii, 16; Orban: Prag. med. Wochenschr., 1899, xxiv, 427. 

2 Miura: Zeitschr. f. Biol., 1895, xxxii, 266. 

3 Pottevin: Compt. rend, de la Soc. biol., 1900, lii, 589. 

4 Kerley, Mason and Craig: Arch. Pediat., 1906, xxiii, 489. 

6 Hecht: "Die Faeces des Sauglings und des Kindes," Berlin, 1910. 



34 DIGESTION OF CARBOHYDRATES 

ent both in the fetus and in the newly-born. Hess 1 always found 
it present during the first week of life, the amount of the ferment 
increasing with the age of the infant. Young babies are, neverthe- 
less, able to adapt themselves to a food rich in carbohydrates. 
There is according to Moro, 2 a rapid increase in the power of 
digesting starch during the first week of life. The baby, therefore, 
has a power of digesting starch at birth which gradually increases 
in strength as the baby grows older. It can digest twice as much 
at eight months as it can at birth, and at twelve months as much 
as a three year old child. 3 The digestibility of starch is obviously 
dependent on the way it is prepared and cooked. 

The question whether the carbohyrate-splitting ferments are 
affected by disease has been answered only in part. Orban 4 found 
by animal experimentation that an injured intestinal mucous mem- 
brane contained no lactase, and that the stools of babies ill with 
enteritis contained no lactase. Langstein and Steinitz 5 on the 
other hand, always found lactase in the stools of babies ill with 
enteritis, whether mild or severe, acute or chronic. Nothmann 6 
was unable to demonstrate lactase in the stools of seven premature 
babies on the first day post partum, but found it always after milk 
had been fed. 

FOEMS OF CARBOHYDRATES 

The forms of carbohydrates commonly used in infant feeding 
may be divided into the groups given in the following table (taken 
from Reuss 7 ). 



;: Am. Jour. Dis. Children, 1912, iv, 205. 

2 Moro: Jahrb. f. Kinderh., 1898, xlvii, 342. 

3 Finizio: Rev. d. Hyg. et Med. Inf., 1909, viii, 224. 
4 OrMn: Prag. med. Wochenschr., 1899, xxiv, 427. 

6 Langstein and Steinitz : Hoffmeister's Beitrage, 1909, vii, 575. 

6 Nothmann: Monatsschr. f. Kinderh., 1909-10, viii, 377. 

7 Reuss: Wien. med. Wochenschr., 1910, Ix, Nos. 28, 29, 30. 



DIGESTION OF CARBOHYDRATES 
TABLE 11 



35 



Milk sugar group 



Cane sugar group 



Malt sugar group 



Lactose (milk sugar) 

1 

Dextrose + Galactose 



Saccharose (cane sugar) 

I 

Dextrose + Levulose 



Starch (Amylum) 

I 

Dextrin (Amylo-dextrin) 

i 

Erythro & Achro-dextrin 

J 

Maltose (malt sugar) 

t 

Dextrose + Dextrose 



DIGESTION OF CARBOHYDRATES 

The carbohydrates are broken down during digestion into the 
simplest forms of sugar, the mono-saccharides, by the various fer- 
ments described above. According to Rohmann * a considerable 
amount of the di-saccharides may pass into the intestinal mucous 
membrane and there be split into mono-saccharides. The mono- 
saccharides are carried from the portal vein to the liver, where 
they are transformed into glycogen, the only difference being that 
dextrose is more easily converted than levulose or galactose. 2 
Sugars may also be carried into the blood by way of the thoracic 
duct, 3 but ordinarily very little is absorbed in this manner. The 
pancreas has some influence on this process because extirpation 
of the pancreas in dogs results in sugar in the urine and interferes 
with the formation of glycogen in the liver. The liver actually 
has the property of forming glycogen from sugar. 4 

The purpose of the splitting of the poly- and di-saccharides into 
mono-saccharides is to prepare them for use inside the body, be- 
cause the unsplit carbohydrates are not burned up in the body, but 
are excreted in the urine. The transformation of sugar into glyco- 
gen which is deposited in the liver and muscles, is of great impor- 
tance because this glycogen can be converted again into sugar 
according to the needs of the body. 

1 Rohmann: Pfluger's Arch. 1903, xcv, 533. 

2 Alderhalden: Textbook of Physiological Chemistry, London, 1908. 

3 Hendrix & Sweet: Jour. Biol. Chem., 1917, xxxii, 299. 
4 Grube: Pfluger's Arch., 1905, cvii, 490. 



36 DIGESTION OF CARBOHYDRATES 

There is normally about 0.1 of dextrose in the blood. The 
slightest disturbance of the regulating apparatus will cause a 
hyperglycemia which results in glycosuria. A deficit of sugar in 
the blood is made up from the glycogen deposits. 1 The mono- 
saccharides are absorbed more quickly than the di-saccharides. 2 
Niemann 3 found that a large proportion of infants respond to 
food with an alimentary glycemia but that the intensity varies 
within a wide range. The highest blood sugar (Bang's micro- 
method) is invariably found in infants thriving well on large 
amounts of carbohydrate. Other infants which show only a slight 
amount of alimentary glycemia, as a rule do not thrive on car- 
bohydrates. According to Bergmark 4 feeding cane sugar leads to 
a greater increase in blood sugar than does maltose or lactose, and 
maltose causes a greater increase than lactose. 

A large part of the digestion and absorption of the carbohydrates 
takes place in the upper part of the small intestine. 5 Splitting 
and absorption may also take place in the large intestine. 6 

The bacteria of the stomach and intestines attack not only 
cellulose but other carbohydrates as well. The decomposition of 
the carbohydrates by means of bacteria, in general, is not very 
extensive and depends very much on the external conditions. The 
products formed by their action are chiefly lactic acid, acetic acid, 
formic acid, butyric acid and alcohol with, in addition, the evolu- 
tion of carbon dioxide, hydrogen, and methane. 7 In abnormal 
conditions the bacteria probably play a much more important part 
in the breaking down of carbohydrates. 

Little or no sugar can be found in the stools under normal condi- 
tions, but when the food passes quickly through the intestinal 
canal, as it does when the peristalsis is increased as the result of 
disease or indigestion, sugar may be found in the stools (Hecht). 
Usually, only the products of the decomposition of sugar can be 
isolated. 

Hedenius 8 fed babies on milk mixed with wheat flour, oat 

1 Langstein-Meyer: Sauglings Ernahrung und Sauglingsstoffwechsel, Wies- 
baden 1910. 

2 Hedon: Compt. rend, de la Soc. de Biol., 1900, 29; Nagano: Pfluger's 
Archiv., 1902, xc, 389; Rohmann: Chem. Bei., 1895, xxviii, 2506. 

3 Jahrb. f . Kinderh., 1916, lxxxiii, p. 1. 

4 Bergmark: Jahrb. f. Kinderh., 1914, lxxx, 373. 

5 London and Polowzowa: Zeitschr. f. physiol. Chem., 1906, xlix, 328. 

6 Reach: Arch. f. exp. Path u. Pharm., 1902, xlvii, 230; Schonborn: Diss. 
Wurzburg, 1897; Pehu and Porcher: Rev. d'Hyg. et de Med. Inf., 1910, ix, 1. 

7 Tappeiner, H.: Zeitschr. f. Biol., 1883, xix, 228. 

8 Hedenius: Ueber das Schicksal der Kohlehydrate im Sauglingsdarm. 



DIGESTION OF CARBOHYDRATES 37 

gruel or Keller's malt extract and measured the amount of 
carbohydrate ingested, the amount found in the stools, and the 
acidity of the stools. He found less carbohydrate in the stools 
when simple cereals were used than when the more compli- 
cated mixtures were given. He also found that the more car- 
bohydrate there was in the stool, the greater was its acidity. He 
never found more than 3% of the ingested carbohydrate in the 
stools. 

Raczynski x has shown that in babies sick with what he 
calls "dyspepsia intestinalis acida lactorum," the acidity of 
the intestinal contents is increased and the utilization of fat 
diminished. 

Talbot and Hill 2 found in their case (J. P.), that an increasing 
amount of lactose in the food did not appreciably influence the 
titratable acidity of the stool until a diarrhea commenced. The 
acidity then increased 500% and lactic, acetic, succinic and butyric 
acids were found to be present. This fact seemed to indicate that 
the acid-forming bacteria played an important part in the breaking 
down of the sugar. This assumption finds support in the studies 
of Bahrdt and Bamberg, 3 who concluded that acetic acid was 
more effective in causing diarrhea than the other volatile fatty 
acids, and that it was undoubtedly formed in the small intestine 
through the agency of the intestinal bacteria. 4 Bahrdt and Mc- 
Lean b found that the volatile fatty acids in the stools of infants 
fed on breast milk increased when sugar was added to the milk. 
The same is true of bottle fed infants with acute digestive dis- 
turbances. They are not, however, always due to sugar but may 
also be due to the decomposition of fat. 

Keller 6 has shown that carbohydrates make the digestion of 
protein more complete. Talbot and Hill 2 have recently confirmed 
these findings. A possible explanation of the protein-sparing ac- 
tion of carbohydrates may be found in the work of Kendall and 
Farmer 7 on the metabolism of bacteria. They found that in the 
test-tube, when sugar was present in the food, less ammonia nitro- 
gen was formed than when sugar was absent. If the results ob- 

1 Raczynski: Wien. klin. Wochenschr, 1903, xvi, 342. 

2 Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218; Weill & Du- 
fourt: La. Nourrisson, 1914, ii 65. 

3 Zeitschr. f. Kinderh., 1912, iii, 322. 

4 Edelstein and Csonka: Biochem. Zeitschr., 1912, xlii, 372. 

5 Bhardt and McLean: Zeitschr. f. Kinderh., 1914, xi, 143. 

6 Keller: "Des Kindes Ernahrung," etc., — loc. cit. 

7 Kendall and Farmer: Jour. Biol. Chem., 1912, xii, 13; 1912, Nos. 1, 2 and 
3; 1912-13, xiii, 63. 



38 METABOLISM OF CARBOHYDRATES 

tained in the test-tube are applicable to the intestinal canal, the 
reason that more nitrogen is retained in the body when sugar is 
present is not because the sugar makes the nitrogen more easily 
absorbable, but because the intestinal bacteria use the sugar in 
preference to the protein and form less nitrogen to be carried away 
in the stools. In other words, the bacteria leave a larger amount of 
nitrogen for absorption than when they grow on a sugar-free pro- 
tein. Cathcart * and Janney 2 suggest that carbohydrates are es- 
sential to protein synthesis. Kocher 3 showed that lactic acid also 
spared protein. His work adds support to the possibility that the 
combination of ammonia, a product of protein metabolism with 
the dissociation products of glucose to form new proteins, is the 
mechanism by which this sparing action is effected. 

Albertoni 4 and Hedon 5 found that sugars have a purgative 
action when they are given in large enough amounts. This action 
is more marked when they are taken in concentrated solution. 
All sugars have this action, the difference between them being 
only in degree. They found that glucose and cane sugar are much 
more quickly absorbed than lactose, and that glucose has less of a 
purgative action than the cane sugar. According to the extensive 
experiments of Rohmann and Nagano 6 saccharose is absorbed 
more quickly than maltose. 

Block 7 reports instances of infants fed on an exclusive carbo- 
hydrate diet, who seemed to be fat and well, but suddenly be- 
came ill and died. They had either sclerema or oedema. 

METABOLISM OF CARBOHYDRATES 

Numerous observations 8 have shown that when milk sugar is 
injected directly into the circulation it may be completely re- 
covered in the urine. Grosz 9 was never able to detect milk sugar 
in the urine of healthy babies, but found it in the urine of those 
suffering with gastrointestinal disease, in which there was pre- 

1 Cathcart: The Physiology of Protein Metabolism, London, 1912, 121. 

2 Janney: Jour. Biol. Chem., 1916, xxiv, 30. 
3 Kocher: Jour. Biol. Chem., 1916, xxv, 571. 

4 Albertoni: Arch. ital. de Biol., xv, xviii, xxx, xxxv, xxxviii, xl. 

5 Hedon: Compt. rend, de la Soc. de Biol., 1899, 884; ibid., 1900, 29 and 87. 

6 Rohmann and Nagano: quoted by Hammarsten and Mandel, ''Textbook 
of Physiological Chemistry," New York, 1912, 509. 

7 Block: Ugeskrift f. Laeger, 1917, lxxix, no. 8, Abstr. Jour. A. M. A., 
1917, lxviii, 1444. 

8 Voit: Deutsch. Arch, fur klin. Med., 1897, lviii, 523. 

9 Grosz: Jahrb. f. Kinderh., 1892, xxxiv, 83. 



METABOLISM OF CARBOHYDRATES 39 

sumably an absence of lactase in the intestine. Langstein and 
Steinitz 1 repeated Grosz's experiments and in certain instances 
found lactase in the stools at the same time that sugar was being 
excreted in the urine. This sugar was, moreover, not always lac- 
tose, but sometimes galactose, one of the products of the splitting 
of lactose. They tried to explain this as follows: — That some of 
the sugar passes through areas of the intestinal wall made abnormal 
by functional or anatomical lesions before it is completely broken 
up and it is excreted in the urine as an intermediary product of 
metabolism. 

Mendel and Keliner 2 have shown that when cane sugar is in- 
troduced subcutaneously into dogs or cats in doses of one to two 
grams per kilogram of body weight it is not completely recovered 
in the urine. The quantity excreted amounts as a rule to more 
than 65% of that introduced. The excretion begins within a few 
minutes and is usually completed within thirty-six hours. Fisher 
and Moore 3 draw attention to the possibility that the sugar thus 
introduced may be excreted through the walls of the alimentary 
tract and there be digested. These views are supported by Jappelli 
and D'Errico, 4 who conclude from their experiments on dogs that 
when cane sugar is introduced directly into the circulation the 
quantity eliminated in the urine is never equivalent to the amount 
injected. This causes both glycosuria and saccharosuria, the for- 
mer disappearing first. The blood has no power of converting 
cane sugar. According to these writers cane sugar introduced 
intravenously is eliminated into the alimentary tract through the 
gastric mucosa, the salivary glands and, to an insignificant degree,, 
through the bile. The subsequent fate of this component is 
obvious. 

In the year 1906, Finkelstein published the first of a series of 
papers 5 which have caused much discussion as to the etiology of 
the digestive disturbances of infancy. In the first place he opposed 
Czerny's teachings as to the harmfulness of fat in infant feeding. 
He taught that bacteria played no part in the etiology of the 

1 Langstein and Steinitz: Moffmeister's Beitrage, 1906, vii, 575. 

2 Mendel and Keliner: Am. Jour. Physiol., 1910, xxvi, 396. 

3 Fisher and Moore: Am. Jour. Physiol., 1907, xix, 314. 

'' Jappelli: Ref. Maly's Jahresbericht fur Tierchemie, 1905, xxxv, 79. 

5 Finkelstein: Verhandl. Gesellsch. f. Kinderh. (Stuttgart), 1906, xxiii, 117; 
Jahrb. f. Kinderh., 1907, Ixv, 1 and 263; Jahrb. f. Kinderh., 1908, lxviii, 521; 
Deutsch. med. Wochenschr., 1909, xxxv, 191; Finkelstein and Meyer: Jahrb. 
f. Kinderh., 1910, lxxi, 525 and Berliner klin. Woch., 1910, xlvii, 1165. For 
literature and an excellent discussion of the subject, see chapter on "Sugar 
in the Young " in Allen, — "Glycosuria and Diabetes," Harv. Univ. Press, 1913. 



40 METABOLISM OF CARBOHYDRATES 

digestive disturbances of infancy and that the sugars produced 
symptoms of intoxication. He also undertook to prove that the 
albumens were quite harmless. He considered that the most acute 
form of disease of the digestive tract, that accompanied by stupor, 
fever, and sugar in the urine, was the result of an intoxication 
caused by sugar. He blamed lactose for the poisoning of the 
system, and claimed that instantaneuos benefit and cure resulted 
from the complete withdrawal of sugar. Schaps * and Leopold and 
Reuss 2 also thought that lactose and other sugars were pyfogenic. 
In 1909, Finkelstein said, — "It is possible, with the certainty of 
an experiment, by giving a dose of sugar (for example 100 grams 
of a 12.5% lactose solution), to an infant with bowel trouble to 
force up the previously afebrile temperature into fever, practically 
with the same certainty as if one should give it a dose of tubercu- 
lin." His " eiweissmilch " was prepared to cure sugar intoxications. 
He apparently overlooked the fact that it contained 1H% or 
more of the lactose which he considered so poisonous in this con- 
dition. As his theories developed, he decided that the sugar in- 
toxication was not due to a sugar injury alone, but to the actions 
of salts, especially the chlorine-ion combination with sodium. 
Friberger, 3 Schloss, 4 Cobliner, 5 and Nothmann, 6 confirmed Meyer's 
statements concerning the pyrexial effects of sodium-halogen com- 
pounds, while Rosenthal 7 found that in animals neither salt nor 
sugar had any specific pyrogenic action. 

In 1910 Finkelstein and Meyer ascribed intestinal irritation to 
abnormal fermentations. They stated that casein was never 
harmful and that it prevented or diminished acid fermentation. 
They stated, on the other hand, that, as Czerny pointed out, fat 
was more dangerous, but claimed that it was only harmful in a 
bowel irritated by carbohydrate fermentation. They admitted, at 
this time, that human milk was the best food to give in these condi- 
tions, thus abandoning their earlier contention that lactose (which 
is present in large amounts in human milk) is poisonous. 

Helmholz 8 found that 5% solutions of sodium chloride, bromide, 
and iodide injected into rabbits subcutaneously in quantities of 

1 Schaps: Verhandl. Gesellsch. f. Kinderh., 1906, xxiii, 153; Berliner klin. 
Wochenschr., 1907, xliv, 597. 

2 Leopold and Reuss: Monatschr. f. Kinderh., 1909-10, viii, 1 and 453. 

3 Friberger: Munch, med. Wochenschr., 1909, lvi, 1946. 

4 Schloss: Biochem. Zeitschr., 1909, xviii, 14. 

5 Cobliner: Zeitschr. f. Kinderh., ii, 429. 

6 Nothmann: Zeitschr. f. Kinderh., i, 73. 

7 Rosenthal: Jahrb. f. Kinderh., 1909, lxx, 123. 
8 Helmholtz: Arch, of Internal Medicine, 1911, vii, 468. 



METABOLISM OF CARBOHYDRATES 41 

from ten to twenty-five cubic centimeters caused no rise of temper- 
ature in the great majority of experiments. Sodium chloride pro- 
duced a slight rise in temperature when given intravenously in high 
concentration. A 1% solution of sodium chloride may, in excep- 
tional instances, produce a febrile rise in temperature when given 
by mouth. Schlutz 1 confirmed these findings; he found that lac- 
tose alone possesses no distinct pyrogenic action, but that it may 
affect the temperature if it is given in combination with a sodium 
salt when the intestinal tract is diseased. 

Allen 2 studied the effects of sugars in young, nursing animals 
and found that in no instance were there any symptoms of the 
intoxicating action of sugar, even when the animals received so 
much sugar by mouth that they had vomiting and diarrhea. He 
found, furthermore, that subcutaneous injections of glucose had a 
very beneficial action on animals, even when they had glycosuria 
and were doing badly. The evidence at hand is opposed to the be- 
lief that sugar has any specific intoxicating effect or acts as a food 
poison and is in favor of the theory 3 that it is a medium of growth 
for bacteria in which they can develop sufficiently to harm the body 
either by their own activity or by the products which result from 
their activity. 

The limits of assimilation of the different sugars vary and are 
given as follows: 

Grape sugar: In babies, about 5 grams per kilogram (Langstein 
and Meyer). 

Grape sugar: In one month baby, 8.6 grams per kilogram 
(Greenfield). 4 

Galactose: No accurate data. 

Levulose : (Lower for babies than adults) , one gram per kilogram 
(KeUer). 

Maltose: Over 7.7 grams per kilogram (Reuss). 

Lactose: From 3.1-3.6 grams per kilogram (Grosz). 

Porter and Dunn 5 state that as much as 120 gm. of lactose may 
be added to the food of infants with indigestion in twenty-four 
hours without appearing in the urine in sufficient quantities to 
be determined quantitatively. 

Cane sugar: Probably about the same as lactose (Reuss). 

The main facts which are apparently true about the metabolism 

1 Schlutz: Am. Jour. Dis. Children, 1912, iii, 95. 

2 Allen: "Glycosuria and Diabetes," Harvard Univ. Press, 1913. 

3 Escherich: Deutsche Klinik, 1902, vii, 126. 

4 Greenfield: Jahrb. f. Kinderh., 1903, lviii, 666. 

6 Porter and Dunn: Am. Jour. Dis. Ch., 1915, x, 77. 



42 METABOLISM OF CARBOHYDRATES 

of carbohydrates in infancy are: — carbohydrates are absorbed up 
to a certain point, lactose being absorbed more slowly than the 
other di-saccharides. Up to a certain point lactose and maltose 
increase the retention of nitrogen, but apparently have no or only 
slight beneficial effect on the retention of ash or the absorption 
of fats. Carbohydrates may increase the retention of sodium and 
water. The large pasty infant fed on a high carbohydrate mixture 
is an example of the effect of a large retention of water. Carbo- 
hydrates may also be deposited in the body in the form of fat. 
When too much sugar is given to an infant there is a marked in- 
crease in the acidity of the intestinal canal and an increased 
peristalsis, which washes the irritating food out of the bowels as 
quickly as possible. Large amounts of fat, protein and ash are 
carried out in the stools, resulting in a diminished absorption and 
retention of these food components. Some of the elements of ash 
are lost to a greater extent than others and their loss may be so 
large that the output surpasses the intake. Under such circum- 
stances the organism is drained of part of its own mineral content. 

Starches act in the same manner as the other carbohydrates 
except that having a more complicated molecule, they go through 
one more step in the process of their conversion into a mono- 
saccharide. 

Marriott in a paper presented before the American Medical 
Association, June, 1919, shows conclusively that Finkelstein's 
theories have no scientific background. Marriott's conclusions 
should be consulted on the publication of his paper. 



CHAPTER IV 
THE DIGESTION AND METABOLISM OF PROTEIN 

FERMENTS 

The saliva of man was shown to contain a proteolytic ferment 
by Ed. Muller, 1 but up to date such a ferment has not been found 
in infants. 

Pepsin was first demonstrated in the mucous membrane of the 
infant's stomach by Zweifel 2 and later Langendorff 3 extracted 
it with HC1 from the stomach of a fetus of four months, at which 
time there is microscopic evidence of glandular formation. The 
amount of pepsin increases with the age of the baby up to the 
third month, and from then on remains constant in amount; it is 
present in larger quantities in bottle-fed babies than in breast-fed 
babies. 4 Pechstein 5 examined the urines of babies at different 
ages and under different conditions and found that all babies 
excrete pepsin and rennin in their urine from the day of their 
birth onward. These ferments are present only in the form of 
their pro-ferments. They are found in minute quantities in the 
early days of life and increase in amount up to the end of the first 
year, at which there is about time one-twentieth as much as in the 
adult. The urine of the artificially-fed baby contains more than 
does that of the breast-fed baby. During an acute disturbance 
of digestion they are as abundant as in health, but during chronic 
diseases they seem to be slightly diminished in amount. When 
pepsin and rennin are fed to a baby, no traces are found in the 
urine, and there is no increase in the amount of rennin in the 
stool. The ferments must, therefore, have been destroyed in the 
upper intestine or neutralized in the blood stream. If the intestinal 
mucous membrane is damaged, the ferments appear in the urine. 

Rennin and hydrochloric acid are found in the first days of 

1 Ed. Miiller: Verhandl. d. Cong, fiir inn. Med., 1908, 676. 

2 Zweifel: Untersuchungen iiber den Verdauungsapparat der Neugeborenen, 
Berlin, 1874. 

3 Langendorff: Arch, fiir Anat. u. Physiol., 1879, 95. 
4 Rosenstern: Berl. klin. Wochenschr., 1908, 542. 

6 Pechstein: Zeitschr. f. Kinderh., 1911, i, 365. 

43 



44 DIGESTION OF PROTEIN 

life. 1 Rennin has been demonstrated in sterile meconium 2 and 
a rennin ferment which acts independently of the stomach and 
pancreas 3 has been found in the stool. 

Trypsin. — Zweifel demonstrated trypsin in the pancreatic ex- 
tracts of new-born babies, and Langendorff found it at the be- 
ginning of the fifth month of fetal hfe. Ibrahim 4 showed that 
when absolutely fresh material was used only the pro-ferment 
trypsinogen is present in the pancreas of the fetus, but that small 
amounts of trypsin may be present in the pancreas of older chil- 
dren. This can be markedly increased by activating it with enter- 
okinase. The pro-ferments are apparently activated by bacteria, 
which are, of course, not present in the intestinal canal of the fetus. 
He was able to demonstrate trypsinogen in a six-months-old fetus. 

Trypsin is found in the feces in small amounts in health and in 
large amounts during diarrhea caused either by drugs or disease. 
Sterile meconium has the property of dissolving gelatine. 5 Hecht 6 
demonstrated trypsin in the stools of babies as early as the first 
day of life. 

Wienland 7 found anti-pepsin in the stomach and anti-trypsin 
in the intestinal mucous membranes; he believed that their func- 
tion was to prevent auto-digestion. Cohnheim 8 believes that anti- 
trypsin is identical with enterokinase and that in small amounts it 
activates trypsin, and in large amounts prevents its action. 

Enterokinase. — The ferment which activates trypsinogen was 
first found by Ibrahim, who extracted it from the intestinal mu- 
cous membrane of new-born babies, and from meconium. It is 
most active in the lower third of the intestine in the majority 
of instances; it may also be obtained from the mucous membrane 
of the large intestine. It apparently first appears in embryonic 
Hfe at the same time that trypsin is found in the pancreas. 

Secretin, according to Bayliss and Starling, 9 is necessary for 
the activation of the pancreas. It may be extracted from the 
intestinal mucous membrane; it is not destroyed by heat, and 
belongs to the group of hormones. When injected intravenously 
it causes a flow of pancreatic juice in about one minute. Ibrahim 

iSzydlowski: Jahrb. f. Kinderh., 1892, xxxiv, 411. 

2 Pottevin: Compt. rend, de la Soc. de Biol., 1900, lii, 589. 

3 Th. Pfeiffer: Zeitschr. f. Exp. Path. u. Therap., 1906, iii, 381. 

4 Ibrahim: Gesellschaft Deutscher Naturforscher und Artzte in Coin, 1908. 

5 Pottevin: loc. cit. 

6 Hecht: Wien. klin. Wochenschr., 1908, xxi, 1550. 
'Wienland: Zeitschr. f. Biol., 1903, xliv, pt. I. 

8 Cohnheim: Nagel's Handbuch d. Physiol., 1907, ii, 5°<7. 

9 Bayliss and Starling: Jour. Physiol., 1902, xxviii, 325. 



DIGESTION OF PROTEIN 45 

and Gross * found it in babies who died at birth, but not in pre- 
mature babies. Wentworth 2 found it absent or present only in 
small amounts in newly-born babies. He found definite but weak 
action in a premature baby which had lived three weeks. Older 
babies, which had died of other diseases than those of the digestive 
tract, all showed a definitely active secretin. Hallion and Le- 
queux 3 found secretin in the upper part of the intestine of two 
newly-born babies, but were unable to find it in the lower part of 
the intestine. They obtained the same results in a five months' 
fetus. There is no record of secretin being found in the feces. 

Erepsin was first demonstrated in the intestinal mucous mem- 
brane by Cohnheim. 4 It changes albumoses and peptones very 
rapidly into amino- and diamino-acids, so that the Biuret reaction 
disappears. It has no action upon the native albumens with the 
exception of casein. It is present in all babies, including pre- 
mature infants. 5 

Lust 6 found an anti-proteolytic ferment in the blood of an 
infant fourteen days old, which had the same anti-trj'ptic power as 
that in the blood of an infant of one year. There is no increased 
formation of this ferment in digestive disorders, while in some 
cases of alimentary intoxication, in which there is loss of protein 
from the body, there is an increased amount of the anti-ferment. 

Mitra 7 was unable to find nuclease or connectivase which could 
digest muscle fibre and connective tissue in the stomach of an 
infant twelve months old, but found both ferments in a child of 
fifteen months. Rossi 8 measured the stimulating effect of saliva 
on the pepsin digestion by the Mett method. He found it greatest 
in the early stages of digestion but it became almost imperceptible 
at the end of four hours. Wakabayashi and Wohlgemuth 9 found 
that the large intestine contains erepsin, nuclease, hemolysin and a 
fibrin enzyme. 

The changes which protein undergoes during digestion may be 
briefly enumerated as follows: 

When it is ingested it is split and hydrolyzed by the various 

1 Ibrahim and Gross: Jahrb. f. Kinderh., 1908, lxviii, 232. 

2 Wentworth: Jour. Am. Med. Assoc, 1907, 119, 204. 

3 Hallion and Lequeux: Compt. Rend, de la Soc. de Biol., Paris, 1906, lxi, 33. 

4 Cohnheim : Zeitschr. f . Physiol. Chemie. Mitteilungen liber das Erepsin, 
1902, xxxv, 134. Notiz iiber das Erepsin, 1906, xlvii, 286. 

6 Langstein: Jahrb. f. Kinderh., 1908, lxvii, 9. 
•Lust: Munchen Med. Wochenschr., lvi, 2047-2051. 

7 Mitra: Folia clinica, hi, 274. 

8 Rossi: Arch. Fisiol., viii, 484; from Zentralbl. Biochem. u. Biophys., ii, 436. 
•Wakabayashi and Wohlgemuth: Internat. Beitr. Path. Therap., ii, 519. 



46 DIGESTION OF PROTEIN 

ferments in a definite sequence. Pepsin reduces it into albumoses 
and peptones. Trypsin and erepsin then split these bodies further 
into amino acids, with an intermediary stage of polypeptides. The 
end products of protein digestion are amino acids and their combi- 
nations. 

Folin and Denis * and Van Slyke and Meyer 2 showed that the 
amino acids are absorbed as such from the alimentary tract. The 
evidence adduced by these observers that the amino acids reach 
the blood stream as amino acids and are carried to the tissues to be 
used in the formation of new tissue or to be disintegrated with the 
resultant production of the end product urea, has been strength- 
ened by the work of London. 3 Recent investigations on dogs 
seem to prove that the amino nitrogen is absorbed both through 
the blood vessels and the lymphatic system. 4 During digestion the 
amount of amino-nitrogen increases not only in the portal blood 
but also in the peripheral circulation. 

CASEIN CURDS 

Twenty-eight years ago Biedert 5 published the first of a series 
of papers, in which he tried to show that many of the disturb- 
ances of digestion in infancy were due to difficulty in digesting 
casein. He believed that the bean-like masses which appeared 
in the stools of artificially-fed babies during disturbances of di- 
gestion were either casein or one of its derivatives. He found 
that their microscopic appearance was similar to that of coagulated 
casein and that they turned pink with Million's reagent. Weg- 
scheider, 6 Uffelmann, 7 Escherich, 8 and Fr. Muller 9 were unable to 
confirm Biedert's assumption and concluded from their own ex- 
periments that the " so-called casein curds" were formed of cal- 
cium soaps, epithelium, bacteria, and intestinal secretions. It 
was shown, furthermore, that Biedert's methods of proving the 

1 Folin and Denis: Jour, of Biol. Chem., 1912, xi, 87 and subsequent 
papers 

2 Van Slyke and Meyer: Jour. Biol. Chem., 1912, xii, 399. 

3 London: Zeitschr. f. Physiol. Chem., 1913, lxxxvii, 313. 

4 Hendrix and Sweet: Jour. Biol. Chem., 1917, xxxii, 299. 
6 Biedert: Jahrb. f. Kinderh., 1888, xxviii, 21. 

6 Wegscheider: Ueber normale Verdauung bei Sauglingen. Innaug. Diss. 
Strassburg, 1875; cited by Blauberg: Experimentelle und kritische Studien 
iiber Sauglingsfeces bei naturliche u. kunstlicher Ernahrung, Berlin, 1897. 

7 Uffelmann: Deutsch. Arch. f. klin. Med., 1881, xxviii, 437. 

8 Escherich: Jahrb. fur Kinderh., 1888, xxvii, 100. 
9 Fr. Muller: Zeitschr. fiir Biol., 1884, xx, 327. 



DIGESTION OF PROTEIN 



47 



presence of casein 1 were of no positive value since nucleo-protein 
and nucleo-albumen gave the same tests. 2 

Talbot 3 showed that there are two kinds of curds, one of which 
is large and tough and contains a high percentage of protein, and 
the other which is small and soft and contains a low percentage of 
nitrogen and a high percentage of fat. The former are tough, 
bean-like masses of varying size and shape, weighing from 34 to 
\}/2 gm., the color varying from white to greenish-yellow according 
to how much' they are stained by the bile and intestinal secretions. 
They may be easily separated from the fecal material in which 
they are imbedded and become extremely hard when treated with 
10% formaline solution. These curds are the ones examined by 
Biedert. The small, soft curds are either flat, white flakes (which 
look like undigested particles of milk) or pinhead elevations, which 
are stained green or yellow by the intestinal secretions. They 
are always associated with more or less mucus and are composed 
almost entirely of fat in the form of fatty acids or soaps. These 
curds are probably the ones examined by Biedert's opponents. 

Knopfelmacher 4 and Selter 5 examined the tough curds chem- 
ically and concluded that they were composed of casein. 

The chemical composition of casein curds is as follows: 



TABLE 12 





Fat in food 

% 


Curds 


Neutral 

fat. % 

of dried 

stool 


Fatty 
acid. % 
of dried 

stool 


Soaps. 
%of 
dried 
stool 


Author 


Nitro- 
gen. % 
of dried 
stool 


Total 
fat. % 
of dried 

stool 


Talbot 4 


3.75 

3.50 

"Eiweissmilch" 

2.3 

1.8 
"Fat free milk" 


7.2 
9.8 
10.4 
10.6 
10.6 
12.0 


46.8 
28. 
27. 
22.3 
19.0 
8.4 


36.4 
21.4 

2.2 


4.6 
1.2 

0.8 


5.8 


Benjamin 5 

Courtney 6 

Talbot 4 


5.6 

5.4 







4 Talbot: Boston Med. and Surg. Jour., 1908, clviii, 905. 
6 Benjamin: Zeitschr. f. Kinderh., 1914, x, 185. 
6 Courtney: Am. Jour. Dis. Children, 1912, iii,l. 

1 Biedert: Arch. f. Gynak., 1907, lxxxi, 1. 

2 See also South-worth and Schloss: Arch. Pediatrics, 1909, xxvi, 241. 

3 Talbot: Boston Med. and Surg. Jour., 1908, clviii, 905; and ibid., Jan. 7, 1909. 

4 Knopfelmacher: Wien. klin. Wochenschr., 1898, 1024; ibid., 1899, 1015; 
ibid., 1899, No. 52, 1038; and Jahrb. f. Kinderh., 1900, lii, 545. 

6 Selter: Verhandl. d. Gesellsch. f. Kinderh., Stuttgart, 1906, 177. 



48 DIGESTION OF PROTEIN 

The foregoing table gives analyses of selected curds from three 
investigators and shows the general tendency for the amount of 
fat in the curd to increase with the amount of fat in the milk. 
Conversely the amount of nitrogen diminishes as the fat increases. 
This seems to indicate that fat, the accidental component of the 
curd, dilutes the nitrogen. 

These experiments were not considered conclusive by most 
pediatricians, especially those of the schools of Czerny, Finkelstein 
and Heubner, while Biedert and many American schools thought 
that they were casein. Wernstedt 1 compared under the micro- 
scope and microchemically the tough curds found in the stool 
with those found in the stomach and concluded that they were 
casein. 

Recently, Talbot, Bauer, Uffenheimer and Takeno 2 working at 
approximately the same time with different methods, showed 
by the precipitine method, by anaphylaxis, and by complement 
fixation that the protein in tough curds was cow casein. Liwschiz 3 
repeated this work and found that casein could be differentiated 
from paracasein by complement fixation. 

When milk curdles in the infant's stomach it entangles a large 
proportion of the milk fat in its meshes and only such fat as lies 
near the surface of the curd can be reached by the digestive juices. 
The amount of fat in the curd depends upon the amount of fat in 
the milk. 4 Courtney 5 did not find any great variation in the 
percentage of fat in the curds examined by her. This is what would 
be expected, because there was no great variation in the percentage 
of fat in the food of the babies passing the curds. She went fur- 
ther, however, and examined the stool mass surrounding the curds 
and concluded that the casein curds are not pathognomonic of any 
pathological condition, and that the loss of food occasioned by 
their formation and the impairment of the general nutrition re- 
sulting from it is insignificant. Finally, that in attempting to cor- 
rect the state of digestion one should be guided by the general 
rules of infant feeding, paying only secondary attention to the 
appearance or disappearance of curds from the stools. 

Howland 6 believes that the presence of casein curds in the stools 

1 Wernstedt: Hygiea, 1907, No. 9, ref. Munchen Med. Wochenschr., 1907, 
2543. 

2 Talbot: Arch. Pediat., 1910, xxviii, 440; Uffenheimer and Takeno: Zeits. 
f. Kinderh., 1911, ii, 32; Bauer: Monatschr. f. Kinderh., 1911, x, 239. 

3 Liwschiz: Diss. Munchen 1913,Zeitschr. f. Kinderh., Ref., 1914, viii, 345. 

4 Talbot: loc. cU. 

5 Courtney: Am. Jour. Dis. Children, 1912, iii, 1. 

6 Howland: Am. Jour. Dis. Children, 1913, v. 390. 



DIGESTION OF PROTEIN 49 

is of " limited, if any, pathological importance, but rather depends 
on physical conditions in the gastrointestinal tract." Benjamin * 
notes that casein curds appear in the stools of healthy as well as 
of dyspeptic infants and that there is less gain in weight while these 
curds are being passed than when they are absent. There is no 
question, however, that the casein curds are relatively rare in in- 
fants' stools and that their presence is often associated with 
symptoms of indigestion. 

Ibrahim 2 and Brennemann 3 observed that the casein curds 
appeared in the stools of babies fed on raw milk and disappeared 
from the stools when the milk was boiled. They both suggest boil- 
ing as a therapeutic measure for preventing the formation of such 
curds. This fact explains why casein curds are seldom seen in 
Germany where the milk is almost universally boiled. 

Ibrahim observed that the curds seem to come more easily in 
babies with digestive disturbances, but that they may come in 
otherwise healthy babies who are fed on raw milk. He saw them 
in a two and one-half year old child which had a typical " digestion- 
insufficiency " as described by Heubner. 4 The most recent experi- 
ments of Uffenheimer 5 seem to indicate that casein is present in 
the stools more frequently than was formerly thought, as it has 
been found in the salve-like skimmed milk stools. 

Selter 6 described a picture of "intoxication" in which there 
is an excursion of temperature from 37° to 34° (i. e., subnormal), 
slow pulse and superficial respiration. The color of the skin is 
bluish-gray. The urine contains no reducing substance. The 
stools are curdy and grayish-yellow, with a cheesy odor. The 
urine contains a kenotoxine, which, when injected into mice, 
causes a condition similar to that described in the babies. The 
disease is cured by small amounts of breast milk, or by carbohy- 
drates, and is attributed to the proteins. 

Mellanby 7 believes that a substance known as /3 imidozoly- 
ethylamine is accountable for the symptoms in the acute diar- 
rheas of infants. This substance may be derived from amino-acid 
histidin by the removal of C0 2 and is related to ptomaines. 

benjamin: Zeitschr. f. Kinderh., 1914, x, 185. 
'Ibrahim: Monatschr. f. Kinderh., 1911, x, 55. 

3 Brennemann: Am. Jour. Dis. Children, 1911, i, 341. 

4 Heubner: Verhandl. d. Gesellsch. f. Kinderh. in Salzburg, 1909, xxvi, 
169. 

5 Uffenheimer: Sitzung der Miinchen Gesellsch. f. Kinderh., 1911; Munchen 
med. Wochenschr., 1911, 876. 

6 Selter: Deutsch. med. Wochenschr., 1908, 512. 

7 Quart. Jour. Med., 1915-16, ix, 164. 



50 DIGESTION OF PROTEIN 

Schloss l found that in "intestinal intoxication" there was often 
acidosis and an increase of the non-protein nitrogen and urea of the 
blood. Although acidosis plays a definite part in the symptoma- 
tology, and the symptoms are essentially those of uremia, he con- 
cludes that the essential cause is probably some unknown toxic 
agent. The evidence at hand, therefore, strongly suggests that 
some product of protein decomposition is responsible for the symp- 
toms present in "intoxication." It is wise to bear in mind in this 
connection that "intestinal intoxication" is not a disease entity 
but is merely the term given for a group of clinical symptoms. 
Monrad 2 and Morse 3 do not believe with Finkelstein and his 
followers that casein is absolutely harmless, but think that it 
can cause dyspepsia. Holt and Levene 4 found that large quanti- 
ties of casein given by mouth could cause a rise in temperature. 
They observed a rise in temperature in five instances that con- 
tinued until the food was changed, and then subsided to normal. 
Fever occurred only when their "synthetic food" contained six 
per cent of casein. There was a retention of chlorides for three 
or four days preceding the rise in temperature. They call attention 
to the parallelism between this fever and that produced by Vaughan 
by the parenteral injection of protein. Their food contained a 
large amount of salts, however, and it is possible that the fever 
may have been caused by them. 

ANAPHYLAXIS 

The connection between anaphylaxis and the disturbances 
caused by cow's milk has always been a field for speculation. Ham- 
burger 5 believed that foreign protein ("artfremdes Eiweiss") was 
"an irritant to the especially sensitive cells of the infant's ali- 
mentary tract and that the necessity of breaking down the pro- 
tein molecule to such simple substances that they could not be 
injurious after absorption threw an added burden on the digestion 
and one which was unnecessary with milk of the same species." 
Howland 6 has brought forward some evidence against this theory. 
Recent investigations, however, have added positive evidence. 
Moro and Bauer 7 found precipitines in the blood of marantic 

1 Schloss: Am. Jour. Dis. Ch., 1918, xv, 165. 

2 Monrad: Monatsschr. f. Kinderh., 1911, x, 244. 

3 Morse: New York Med. Jour., 1913, xcvii, 477. 

4 Holt and Levene: Med. Klin., 1913, ix, 258. 

6 Hamburger: quoted by Howland, — Am. Jour. Dis. Children, 1913, v. 390. 

6 Howland: Am. Jour. Dis. Children, 1913, v. 390. 

7 Moro and Bauer: quoted by Howland, — Am. Jour. Dis. Children, 1913, 
v. 390. 



DIGESTION OF PROTEIN 51 

infants in a few instances. There is not much doubt that during 
the first weeks of life a foreign protein can pass through the in- 
testinal wall. Schloss 1 and Berger 2 have given indirect, but sug- 
gestive evidence by differential counts of the blood, that when a 
foreign protein is introduced for the first time into the gastro- 
intestinal canal of infants, there is a similar reaction in the body 
to that obtained in active sensitization and immunity of the body. 
These two pieces of work suggest that the sequence of sensitiza- 
tion and immunity takes place when any foreign protein is intro- 
duced into the intestinal canal. Lust 3 fed different forms of for- 
eign protein to children with digestive disturbances and found by 
the precipitine reaction that egg albumen passed through the in- 
testinal wall in nine of sixteen cases of acute and chronic nutritional 
disturbances, while ox serum passed through in only one of seven- 
teen cases. Hahn 4 found that in five out of twenty-three infants 
with acute nutritional disturbances antitoxin passed from the in- 
testine into the blood. Modigliani and Benini 5 found by means 
of the precipitine reaction that the blood of infants fed on cow's 
milk showing symptoms of gastrointestinal disturbances, was al- 
ways positive for cow casein. Sick new-born babies gave a positive 
reaction, while older breast-fed babies were negative even when 
they were given a little cow's milk during an acute intestinal 
disturbance. No healthy infants gave positive reactions. These 
findings have been recently confirmed in a carefully controlled 
piece of work by Schloss and Worthen. 6 Vaughan 7 calls attention 
to the fact that peptone and other products of decomposition of 
protein may cause symptoms of disease and that "sensitization 
may result from the absorption of undigested or partially digested 
proteins from the alimentary tract." 

Differences in the Absorption of Human and Cow's Milk Ni- 
trogen. — In most instances less nitrogen is taken in the food of 
naturally fed babies than in that of artificially-fed ones, but when 
approximately the same amounts of each are ingested there is less 
fecal nitrogen in the artificially-fed babies than in those fed natu- 

1 Schloss: Paper read at the Am. Assoc, for the Study and Adv. of Clinical 
Investigation, May 11, 1914. 

2 Berger: Paper read at the Thirty-fifth meeting of the New England Pedia- 
tric Society, held January 29, 1915. 

3 Lust: Jahrb. f. Kinderh., 1913, lxxvii, 383. 

4 Hahn: Jahrb. f. Kinderh., 1913, lxxvii, 405. 

6 Modigliani and Benini: Policlinico, Rome, Dec. med. Section, 1914, No. 
12, 533. 

6 Schloss and Worthen: Am. Jour. Dis. Ch., 1916, xi, 342. 

7 Vaughan: Jour. Am. Med. Assoc, 1913, lxi, 1761. 



52 DIGESTION OF PROTEIN 

rally. 1 The nitrogen in the feces of both naturally and artificially- 
fed babies increases, other things being equal, with an increase of 
nitrogen in the food. There may, however, be considerable varia- 
tions in the nitrogen excreted by the same child on the same food 
if the observation is continued over a long period of time, as is 
shown by the work of Cronheim and Miiller. 2 

Starvation stools. — Experiments on animals and man have 
shown that during starvation there are only small amounts of ni- 
trogen in the feces, that when a nitrogen-free food is given there is 
considerable increase in the fecal nitrogen 3 and that there may 
be more nitrogen in the stools on a nitrogen-free food than on one 
containing a large amount of nitrogen. It may be assumed, there- 
fore, that the animal albumins are probably completely or al- 
most entirely absorbed in health. It is evident also that the ni- 
trogen in the feces comes principally from the intestinal secretions 
and the intestinal bacteria. Keller 4 found that a baby excreted 
0.74 gm. nitrogen per day in one experiment and 0.097 gm. in 
another, while undergoing starvation. 

It would be expected that when the amount of food is in- 
creased there would be an increased flow of digestive juices, but 
figures do not bear out this assumption. Vegetable nitrogen 
is digested and absorbed with greater difficulty than animal 
nitrogen. Wohlgemuth 5 found that he could cause an increased 
flow of pancreatic juices in a man with a pancreatic fistula 
by feeding carbohydrates and that protein caused a less profuse 
flow. 

Composition of Nitrogenous Bodies in Stools. — It has already 
been shown that tough curds are formed from undigested casein. 
A large part of the remaining fecal material is due to the bodies 
of bacteria. The chemical composition of the nitrogenous com- 
ponents of the stools is as follows: 6 

Proteins and amino acids 50-70% 

Free amino acids 2 . 4-24% 



Ammonia 3.0-37% 



1 See Tables in Keller: Phosphor, und Stickstoff im Sauglingsorganismus. 
Arch. f. Kinderh., 1900, xxix, 1; and Orgler: Ueber Harnsaureausscheidung 
im Sauglingsalter. Jahrb. f. Kinderh., 1908, lxvii, 383. 

2 Cronheim and Miiller: Biochem. Zeitschr., 1908, ix, 76. 

3 Rubner: Zeitschr. f. Biol., 1879, xv, 115, and others. 

4 Keller: Arch. f. Kinderh., 1900, xxix, 1. 

6 Wohlgemuth: Berl. klin. Wochenschr., 1907, 47. 

6 Van Slyke, Courtney and Fales: Am. Jour. Dis. Ch., 1915, ix, 533. 

7 Gamble: Am. Jour. Dis. Ch., ix. 519. 






METABOLISM OF PROTEIN 53 



THE METABOLISM OF PROTEIN 

Schlossmann and Murschhauser l investigated the fasting me- 
tabolism of infants. Their paper should be consulted in the origi- 
nal for the literature and the details of the investigations. They 
found that the nitrogen excretion in the urine during fasting de- 
pended upon the quality of the food ingested before fasting was 
commenced and that the greater the protein (nitrogen) content 
of the food, the greater was the excretion of nitrogen. For ex- 
ample, Baby 14: — 

TABLE 13 

Nitrogen content of urine per Nitrogen content of urine per 

hour, per kilogram hour per kilogram 

Grams Grams 

Feeding with human milk . 00363 Modified cow's milk 0.0119 

On first day of fast 0.00513 First day's fast 0.0160 

On second day of fast . 00686 Second day's fast . 0151 

On third day of fast 0.01083 Food again given 0.0080 

On first day after fast . 0068 

On second day after fast . 0042 

When human milk had been used less body protein was broken 
down during starvation than when modified cow's milk was used. 
After eighteen hours of fasting the nitrogen in the urine represents 
the products of the katabolism of the body protein. The acetone 
bodies increase in the urine during fasting, and the evidence points 
to the absence of carbohydrate in the food as the cause. 

When the amount of protein in the food is increased there is 
increased retention of nitrogen. 2 Babies, unlike adults, are able 
to retain nitrogen even when they are not receiving the required 
number of food calories. They may continue to do so even under 
the most discouraging circumstances. 

In adults when the total carbohydrate of the food is replaced by 
fat of an equal caloric value there is a considerable albumin def- 
icit. 3 If only a part of the carbohydrate is replaced by fat, the 
body will eventually return to a nitrogenous equilibrium. Orgler 
believes that in normal babies, however, the amount of fat in the 
food influences the nitrogen metabolism to only a slight degree. 
Increasing the fat in the food of babies that do not digest fat well 
may, on the other hand, result in a negative nitrogen balance. 
It is not known whether the action of the fat of human milk and 

'Schlossmann and Murschhauser: Biochem. Zeitschr., 1913, lvi, 355. 

'Meyer, L. F.: Biochem. Zeitschr., 1908, xii, 422. 

5 Landergreen: Skandin. Arch. f. Physiol., 1903, xiv, 112. 



54 METABOLISM OF PROTEIN 

of cow's milk is the same or not. In Courtney's cases * the nitro- 
gen retention was higher in those babies which showed a very 
considerable gain in weight in the course of the experiment and 
were, therefore, in the stage of reconvalescence. Fat does not 
seem to have the property of sparing protein. 

Carbohydrates, on the other hand, have a marked property of 
sparing nitrogen. 2 Cane and milk sugar have the same action 
as malt sugar. When they are added to the food there is usually 
an increase in the nitrogen retention. When carbohydrates are 
given in excess, they cause increased peristalsis, frequent stools 
and a considerable loss of nitrogen from the body. 3, 4 

The growing body requires protein from which to build up the 
body tissues, muscles, etc., while carbohydrates and fats are used 
as fuel. It is obvious, therefore, that more protein or nitrogen 
must be ingested than is excreted in order that the needs of the 
growing tissues may be supplied. The osseous system, in the same 
way, requires mineral salts for its growth, and more salts must be 
ingested in the food than are lost in the excreta. These salts which 
are retained in the body are used to build up new bone. When the 
baby is gaining weight and strength, there is a retention of both 
nitrogen and salts and when the baby is not gaining, there may be 
a loss of both of these bodies. When one is retained in the body the 
other is apt to be retained, and vice versa, as shown by Orgler's 
Baby No. 9. 5 

The metabolism of breast-fed babies can be compared more 
easily than of that bottle-fed babies because the food, i. e., breast 
milk, is essentially the same in all cases, while that of artificially- 
fed babies differs a great deal. Orgler found that in general there 
is more nitrogen retained per kilogram of body weight in young 
babies than in older babies; that is, the retention decreases as 
the baby grows older. 

Both the retention and the utilization of nitrogen must be taken 
into consideration when the various cases in literature are com- 
pared. Utilization represents the amount retained as compared 
with the amount in the food. The following table taken from 
Schwarz gives an idea of utilization : 

1 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 

2 Keller: Maltsuppe, eine Nahrung fur magendarmkrauke Sauglings. Jena, 
1903. 

3 Orgler: Jahrb. f. Kinderh., 1908, lxvii, 383. 

4 Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218. 

6 Meyer, L. F.: Ergebniss d. inn. Med. und Kinderh., 1908, i, 317. 



METABOLISM OF PROTEIN 
TABLE 14 



55 



Age 


Up to 14 days 


2-8 months 


5 months 


Retention 


0.351 

78.3% 


0.153 

40.8% 


0.048 


Utilization 


23.1% 







The foregoing table shows that the younger the baby is, the 
greater is the retention and utilization of nitrogen. This cor- 
responds with clinical observations of growth, for the very young 
baby grows very rapidly and, therefore, retains and reuses more 
nitrogen in building up new body tissues than the older baby 
which does not increase so rapidly in size. Under certain con- 
ditions of under-nourishment, an increase in the amount of nitro- 
gen in the food results in an increased retention of nitrogen and 
improvement in the general condition of the baby. 

Baby F. W. L. studied by Talbot and Gamble l gained weight 
rapidly and retained increasing amounts of nitrogen as the ni- 
trogen in the food was increased until period 5, when the greatest 
amount of protein was given in the food, and as a result casein 
curds appeared in the feces, and less nitrogen was retained. 
Coincidently symptoms of indigestion appeared and the baby 
refused to take all its food. These figures are the only ones 
which show that casein curds in the stools represent an increased 
excretion of nitrogen from the body. They are probably the 
only true record of the metabolism during protein indigestion. 

In other conditions an increase of the food nitrogen causes greater 
retention but not necessarily a gain in weight. There is no ex- 
planation of why this increase in the retention of nitrogen does not 
necessarily benefit the baby. Sick infants cannot retain as much 
nitrogen as well babies of the same age. Fife and Veeder 2 found 
that two cases of infantile atrophy had a greater retention of ni- 
trogen than normal babies of the "same age and weight." The 
question may be raised, however, as to whether the babies examined 
could have been atrophic if they were of the same weight as nor- 
mal babies of the same age. When the amount of carbohydrate in 
the food was increased there was increased retention of nitrogen 
but the nitrogen retention was not influenced by the amount of 
fat in the food. 

Czerny and Steinitz 3 have collected the figures of the nitrogen 

1 Talbot and Gamble: Am. Jour. Dis. Ch., 1916, xii, 333. 

2 Fife and Veeder: Am. Jour. Dis. Children, 1911, ii, 19. 

3 Czerny and Steinitz: Stoffwechselpathologie des Kindes, Noorden's Hand- 
buch d. Path. d. Stoffwechsels, II, 391. 



56 METABOLISM OF PROTEIN 

metabolism of infants with disturbances of digestion and found 
that the absorption was approximately normal except during 
diarrhea. Although the evidence all seems to show that there is a 
retention of nitrogen in practically all instances, yet this evidence 
is not sufficient to warrant its acceptance without reserve. Gam- 
ble, 1 has shown that in alkaline stools twenty per cent of the ni- 
trogen can be lost in the form of ammonia during the process of 
drying. This loss of nitrogen has not been taken into considera- 
tion in the metabolism experiments of other writers and might 
be sufficient to result in a negative balance of nitrogen in some 
of the instances in which the balance has been reported 
positive. 

Protein Needs of Infants. — The increasing tendency to feed 
infants on dilutions of whole milk also necessitates giving larger 
amounts of protein in the food than is required by the body for 
growth. During metabolism the very process of digestion uses 
up energy. It has been shown repeatedly that the increase of 
metabolism due to fat or carbohydrate is very slight, but that 
the increase incident to protein hydrolysis may be 30%. 2 It, 
therefore, seems uneconomical to burden the digestion any more 
than is necessary with the food component which uses up so much 
energy in preparing itself for use. The figure commonly given 
as the caloric needs of infants is 2 grams of protein per kilogram 
of body weight. Hoobler 2 considers that the protein needs will 
be supplied for growth if 7% of the food calories are in the 
form of protein. 3 This figure is probably a little too low for the 
average infant. It has also the additional disadvantage that 
it requires a relatively high amount of fat and sugar to supply 
enough calories. It is, therefore, safer to figure that 2 grams of 
protein per kilogram of body weight is the lowest amount of 
protein on which an infant can thrive, that it is wise to keep the 
amount of protein relatively low, but never lower than this point, 
and that larger amounts may be given, if the digestion is such 
that sufficient calories cannot be supplied in fat and carbo- 
hydrate. 

Vitamines. — Although the food may contain enough calories and 
protein to supply the requirements of an infant, it may not con- 
tain the proper "vitamines" necessary for growth. These are of 
two types and are described by McCollum as fat soluble A and 
water soluble B. Most of the knowledge on this subject is founded 

1 Gamble: Am. Jour. Dis. of Children, 1915, ix, 519. 

2 Lusk: Sc. of Nutrition: Phila. and London, 1917, 3rd Ed., p. 238. 

3 Hoobler: Am. Jour. Dis. Ch., 1915, x, 153. 



METABOLISM OF PROTEIN 57 

on animal feeding experiments * and need not necessarily apply 
to the human infant, but in all probability the fundamental 
principles will be the same in either case. " There is greater 
value in lactalbumen in promoting growth than in casein be- 
cause the amino acids are arranged in more suitable proportions. 
The protein of whey appears to be as perfect a material for use 
in the service of growth as any protein known." * The amino 
acids which play an essential role in growth are lysin, cystin, tryp- 
tophan, and glycocoll, while others may have a minor part. Their 
arrangement and relation to one another must fall within definite 
limits for the optimum results. 

1 See Lusk: Science of Nutrition, 3rd Ed., 1917, Phila. and London, pp. 368 
et seq. 



CHAPTER V 
THE METABOLISM OF THE MINERAL SALTS 

The metabolism of the mineral salts was first investigated by 
Liebig l in 1840. Very little information of value in relation to 
the problems of infant feeding and metabolism has been added 
since then, however, until recent years. Even such information 
as we now have is being continually modified or disproved by 
chemists, who find that the methods which were employed in ob- 
taining the figures gave erroneous results. Summaries of the pres- 
ent knowledge of the metabolism of the mineral salts are given 
by Albu-Neuberg, 2 L. F. Meyer, 3 Hoobler, 4 and Tobler and Bes- 
sau. 5 

The body of the new-born infant is relatively richer in water 
and fat and poorer in nitrogen and ash than the body of the adult. 
The body of the fetus contains a very large proportion of water, 
the proportion diminishing as the fetus grows older. The com- 
position of the ash of the new-born infant is according to Soldner 6 
as follows: 

In one hundred parts of the new-born infant there is K2O, 
7.06; Na 2 0, 7.67; CaO, 38.08; MgO, 1.43; P2O3, 0.11; F 2 3 , 0.83; 
Mn 3 4 , 0.03; S 2 5 , 37.66; So 3 , 2.02; CI, 6.61; Si0 2 , 0.06; Cos, 
0.53. 

Human milk contains, with the exception of iron, much less 
of the mineral salts than cow's milk. More of the salts in human 
milk are in organic combination than in cow's milk and for that 
reason are supposed to be utilized more easily. Soldner 7 found 
that the sodium, potassium, and chlorine content of human milk 
decreased as lactation progressed, while the bone-forming con- 

1 Liebig: Chemie in ihre anwendungs fur Agrikultur und Phys., 1876. 

2 Albu-Neuberg: Mineralstoffwechsel, Berlin, 1906. 

* Meyer, L. F. : Ergebnisse d. inn. Med. u. Kinderh., 1908, i, 317. 

4 Hoobler: Am. Jour. Dis. Children, 1911, ii, 107. 

5 Tobler and Bessau: Allgemeine Pathologische Physiologie der Ernahrung 
und des Stoffwechsels im Kindesalter, Wiesbaden. 

8 Soldner: quoted in Pfaundler and Schlossmann: The Diseases of Children, 
Phila. and London, 1908, i, 364. 
7 Soldner: loc. cit. 



METABOLISM OF SALTS 59 

stituents, calcium, magnesium and phosphorus, remained fairly- 
constant. 

The mineral salts play a very complicated part in digestion, 
because they are not only absorbed by the intestines, but also 
may be re-excreted into the digestive canal. There are also com- 
plicated reactions which take place between the organic and in- 
organic food components. 

The digestive juices contain salts. Bile contains from J/£ to 
1% of ash, which is especially rich in sodium and chlorides. 1 It 
also contains smaller amounts of potassium ; calcium, and mag- 
nesium in combination with phosphoric acid. The pancreatic 
juices contain J^% of ash, the greater part of which is in the form 
of sodium carbonate. The intestinal secretions are also rich in 
carbonates. 

Metabolism of Ash. — Cow's milk contains much more ash than 
human milk, and, therefore, much more salt is given to the in- 
fant taking an artificial food prepared with cow's milk than it 
requires. The breast-fed infant 2 absorbs about 80% of the ash in 
the food and retains between 40% and 50% while the artificially- 
fed infant absorbs from 43% to 78% and retains from 43% 3 to 
none at all or may even loose ash from the body. 4 Hoobler 3 found, 
in his experiments, that the retention of mineral salts as compared 
with the retention of nitrogen was relatively poor. The retention 
was poorest when the food contained but little fat, was better 
when it contained a medium amount of fat, and was best when 
it contained a large amount of fat (5.4%). Talbot and Hill 4 
kept the fat and protein in the food approximately the same in 
seven periods, and found that when the carbohydrate was in- 
creased beyond the limit of tolerance and diarrhea resulted there 
was a loss of ash from the body. The increased excretion of ash 
was through the feces. A careful study by Holt and his co-workers 5 
showed that in loose stools as much as 84% of the intake may be 
lost, the principal loss being salts other than calcium phosphate. 
Chlorin, potassium and sodium are normally present in relatively 
small amounts in normal stools but in loose stools they are ex- 
creted in large enough amounts to result in a loss of sodium and 
potassium from the body. 5 

Metabolism of Calcium. — The metabolism of calcium is de- 

JTobler: loc. cit. 

*Blauberg: Zeitschr. f. Biol., 1900, xl, 1. 

» Hoobler: Am. Jour. Dis. Children, 1911, ii, 107. 

* Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218. 

5 Holt, Courtney and Fales: Am. Jour. Dis. Ch., 1915, ix, 533. 



60 



METABOLISM OF SALTS 



scribed in detail in the chapter on rickets. For that reason it is 
unnecessary to speak of it here except to say that some investiga- 
tors criticise the methods which were used to quantitate the 
amount of calcium and show that they are inaccurate. 

Metabolism of Iron. — The amount of iron in both cow's milk 
and human milk is small and is insufficient for the needs of the 
growing infant. Nature has deposited enough iron in the liver * 
of the new-born infant, however, to last until it can digest foods 
which contain sufficient amounts of iron. The iron in human 
milk is apparently more easily retained than that in the milk of 
animals. The following table of Krasnorgorski 2 illustrates this 
point. 

TABLE 15 





[ron Metabolism op the Same Baby in two 


Periods 




Author 


Food 


Iron in 
food 


Feces 


Urine 


Ab- 

sorbed 

mg. 


Ab- 
sorbed 
% 


Re- 
tained 
mg. 


Re- 
tained 
% 


Krasnor- 
gorski 

Krasnor- 
gorski 


Human milk 
Goat's milk 


7.05 mg. 
3.44 " 


0.84 mg. 
2.59 " 


. 55 mg. 
0.09 " 


6.21 
0.85 


88.09 
24.71 


5.66 
0.76 


80.28 
22.09 



Metabolism of Magnesium. — The absorption and retention of 
magnesium are higher in the breast-fed than in the artificially- 
fed infant. Hoobler 3 found that when an infant was taking an 
artificial food the retention was better when there was a low per- 
centage of fat in the food than when there was a high percentage 
of fat. 

Metabolism of Phosphorus. — One liter of human milk contains 
from 0.31 to 0.45 gram of phosphorus and one liter of cow's milk 
about 1.81 grams. Three-quarters of the phosphorus in human 
milk is in organic combination, while only one-quarter of the phos- 
phorus in cow's milk is in organic combination; 41.5% of the 
total phosphorus in human milk is in the form of nucleon phos- 
phorus and only 6% in cow's milk. 

According to Blauberg 4 89.2% of the phosphorus in human 
milk and 53.2% of that in cow's milk is absorbed. Hoobler 3 found 



1 Bunge: Zeitschr. f. Physiol. Chemie, 1889, xiii, 399. 

2 Quoted by L. F. Meyer: Ergeb. d. inn. Med. u. Kinderh., 1908, i, 327. 

3 Hoobler: he. cit. 

* Blauberg: see Hoobler, loc. cit. 



METABOLISM OF SALTS 61 

that more was absorbed when the food contained a high per cent, 
than when it contained a low per cent, of fat. Knox and Tracy * 
confirmed the work of Keller showing that the bottle-fed baby- 
excretes much more phosphorus in the urine than the breast-fed 
infant. The latter excretes very little or none. According to 
L. F. Meyer, 2 the retention of phosphorus is less in the artificially- 
fed than in the breast-fed infant, the former retaining about 30% 
of the intake and the latter 69.13%. 

Metabolism of Sodium and Potassium. — There is more potas- 
sium than sodium in milk. Human milk contains less sodium and 
potassium than cow's milk. The absorption of these salts is good 
for both milks. The retention is better on human milk than on 
cow's milk, being 67% for sodium and 74% for potassium on 
human milk, while on cow's milk it is 15.27% for sodium and 
16.12% for potassium. Both salts are eliminated in both the 
urine and feces, from 15% to 25% of the intake being eliminated 
in the feces. 3 

Metabolism of Chlorides. — Very little is known about the me- 
tabolism of the chlorides. 

Metabolism of Sulphur. — Hoobler finds that the sulphur of both 
human and cow's milk is well absorbed, the absorption taking place 
principally in the small intestine. Sulphur is eliminated almost 
entirely through the urine, but a small part is eliminated into the 
large intestine. The retention of sulphur is better when human 
milk is taken than when cow's milk is taken. 

The Influence of the Various Food Components on the 
Metabolism of the Mineral Salts. — There are very few in- 
vestigations which throw any light on the influence of the 
individual food components on the metabolism of the mineral 



Howland 4 found that carbohydrates increased the retention of 
calcium. 

L. F. Meyer found that the addition of casein to the food di- 
minished the absorption of all the mineral salts. 

Steinitz 5 Rothberg 6 and Birk 7 found that as the fat in the 

1 Knox and Tracy: Am. Jour. Dis. Children, 1914, vii, 409. 

2 Meyer, L. F.: Ergeb. d. inn. Med. u. Kinderh., 1908, i, 317. 

5 Hoobler: Am. Jour. Dis. Children, 1911, ii, 107. See table and references. 
4 Howland (not yet published). Read before the Am. Ped. Soc'y, Wash., 

1913. 

6 Steinitz: Monatsschr. f. Kinderh., 1902-3, i, 225; Jahrb. f. Kinderh. 1903, 
lvii, 689. 

6 Rothberg: Jahrb. f. Kinderh., 1907 lxvi, 69. 

7 Birk: Jahrb. f. Kinderh., 1907, lxvi, 300. 



62 METABOLISM OF SALTS 

food was increased the loss of mineral salts in the feces was 
also increased. This loss was especially of calcium and mag- 
nesium and sometimes resulted in a negative balance. Court- 
ney * on the other hand, did not find that fat had any marked 
influence on the retention of ash in infants with chronic in- 
digestion. 

L. F. Meyer 2 found that infants with "Bilanzstorung" lost 
from 34% to 6 X 0% of the ash in the food through the feces as com- 
pared with from 20% to 25% in normal cases. In the stage of in- 
toxication he found that more sodium, potassium, and chloride 
were lost in the feces but that there could still be a retention of 
calcium and phosphorus. There is always a loss of ash from the 
body 3 in acute diarrhea, although even under these circumstances 
a retention of calcium is possible. The reverse is apparently true 
when "soap stools" are passed. 

Relation of (Edema to Salts. — (Edema is due to a retention of 
salts in the body. This connection between the two is shown by 
the analyses of Klose 4 who examined post-mortem the bodies of 
normal and cedematous infants. He found that 29% of the 
water content of the body in a normal infant was in the muscles 
and 21% in the skin and subcutaneous tissue, while in infants 
with oedema there was slightly less fluid in the muscles and much 
more than the normal amount in the skin and subcutaneous tis- 
sue. Apparently there is much less subcutaneous fat in cedema- 
tous infants than in the normal but in its place there is an 
increase in the sodium chloride. 

Diarrhea. — -(See page 33.) During many cases of diarrhea which 
are not of the ileocolitis type, Howland and Marriott 5 have shown 
that there is a diminution of the alkali reserve in the blood and an 
acidosis (see chapter on Acidosis). Judell 6 finds that in diarrhea 
the ash retention is diminished, or in severe grades there is a 
negative balance, the loss being due especially to sodium and 
potassium. Holt 7 and his co-workers found that in diarrhea 
there is relatively a much greater amount of chlorin, sodium and 
potassium in the stool than of calcium and magnesium. There is 
two and a half times as much fat and protein in diarrheal stools 

1 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 

2 Meyer, L. F.: Jahrb. f. Kinderh., 1910, lxxi, 379. 

3 Tobler and Bessau: loc. cit. 

4 Klose: Jahrb. f. Kinderh., 1914, lxxx, 154. 

6 Howland and Marriott: Am. Jour. Dis. Ch., 1916, xi, 309. 

6 Judell: Zeitschr. f. Kinderh., 1913, viii, 235. 

7 Holt: Courtney and Fales, Am. Jour. Ch., 1915, ix, 213. 



METABOLISM OF SALTS 63 

as there is in normal stools. The relation of excretion to intake 
is as follows: — 

Fat: loss in normal stools 12 . 4% of intake 

very loose stools 40.5% " " 

Protein: loss in normal stools 7.7% " " 

loose stools 14.9% " " 

very loose stools 25.2% " " 

Ash: loss in normal stools 40.0% " " 

very loose stools 84.3% " " 



CHAPTER VI 
THE ENERGY METABOLISM OF INFANTS 

The earliest investigation of the gaseous metabolism of infancy 
is that reported by J. Forster, of Munich in 1877. 1 He found 
with the large Pettenkofer-Voit respiration chamber that the in- 
fant produces much more carbon dioxid per unit of weight than 
does the adult. In France Richet, Langlois, Variot and Saint- 
Albin, Bonnoit, Variot and Lavaille 2 and G. Weiss published a 
series of investigations on the metabolism of new-born infants 
and atrophic infants between the years 1885 and 1912. In 1898 
the classical monograph of Rubner and Heubner 3 appeared. 
They studied the average daily requirement of food of a normal 
infant and in the following year 4 of an atrophic infant. They 
point out the fact that in human beings the carbon dioxid excre- 
tion is proportional to the body surface, whatever their size. 

In 1908 the first of a series of investigations by Schlossmann and 
Murschhauser 5 appeared, and this, with subsequent articles, the 
last of which was published in 1914 6 have added much to our 
knowledge of the metabolism of infancy. These authors emphasize 
the influence of muscular activity on metabolism and they studied 
the basal metabolism (Grundumsatz) during complete repose for 
the purpose of comparing the metabolism in health and disease. 
They conclude that slight changes in the temperature of the sur- 
rounding air are without influence on the metabolism. Their in- 
vestigations led them to study also the fasting metabolism in order 
to eliminate the influence of work done during digestion. 

Other investigators, whose names should be mentioned, are 
Mensi, Poppi, Scherer 7 Babak, and Hasselbach, Bahrdt, Birk, 
Edelstein and Niemann. 

1 Forster: Amtl. Ber. d. 50 Versammlung deutsch. Naturforscher u. Aerzte 
in Miinchen, Munich, 1877, 355. 

2 For synopsis of literature see Benedict and Talbot: Gaseous Metabolism 
of Infants, Carnegie Institution of Washington, Publication 201. 

3 Rubner and Heubner: Zeitschr. f. Biol., 1898, xxxvi, 1. 

4 Rubner and Heubner: Zeitschr. f. Biol., 1899, xxxviii, 315. 

6 Schlossmann and Murschhauser: Biochem. Zeitschr., 1908, xiv, 385. 
"Schlossmann and Murschhauser: Biochem. Zeitschr., 1914, lviii, 483. 

7 See Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 

64 



ENERGY METABOLISM 65 

In America, Carpenter and Murlin ' studied the energy metab- 
olism of pregnant women before and after the birth of the child. 

Howland 2 studied the direct calorimetry and compared it with 
the heat calculated from the carbon dioxid excretion and oxygen 
consumption. He found that the heat-production as directly meas- 
ured and as indirectly computed was strikingly close, the greatest 
difference being 2%. Benedict and Talbot 2 reported from 
the Nutrition Laboratory of the Carnegie Institution of Wash- 
ington in 1914, the results of three years' investigations with a 
respiratory chamber on about eighty babies, of which sixty-one 
were reported in detail. Murlin and Hoobler 4 reported the results 
of their investigations with a respiratory chamber on a few in- 
fants in 1915. 

Methods of Computing the Energy Metabolism. — There are 
several ways of computing the energy metabolism of infants : first, 
by measuring the heat lost by an infant in a calorimeter; second, 
by computing the heat production by collecting the carbon dioxid 
excreted and measuring the oxygen consumed by an infant in a 
respiratory chamber. Zuntz 5 has computed the calorific value 
of oxygen with different respiratory quotients and these figures 
may be considered today as the best data we have for the com- 
putation of the energy output from the measurement of the 
gaseous exchange. Knowing the respiratory quotient the calcula- 
tion of the calorific value of carbon dioxid is a simple one. (Bene- 
dict and Talbot, Carnegie Institution of Washington, Publication 
201, Table fifteen, page twenty-nine, gives the calorific equiva- 
lents of carbon dioxid.) 

It is, therefore, possible to determine how many calories are used 
during a given period when the carbon dioxid and the respiratory 
quotient are known; thirdly, the energy metabolism has been com- 
puted by investigators who have measured the fat, carbohydrate 
and protein intake and the loss of fat, carbon and nitrogen in the 
excreta; and finally, the energy metabolism is roughly computed 
by clinicians who know the approximate or theoretical composi- 
tion of the elements in the food. The last method is of little or no 

1 Carpenter and Murlin: Arch. Internal Med., 1911, vii, 184. 

2 Trans. Fifteenth Internat. Cong. Hyg. and Demog., 1911, ii, 438. 

3 Benedict and Talbot: Carnegie Institution of Washington, Publication 
201; and Am. Jour. Dis. Children, 1914, viii, 1. 

4 Murlin and Hoobler: Am. Jour. Dis. Children, 1915, ix, 81. See also 
Bailey and Murlin, Am. Jour, of Obstetrics and Dis. of Women and Children, 
1915, lxxi, 526, for the Metabolism of New-born Babies. 

5 Zuntz, quoted by Benedict and Talbot: Carnegie Publication of Washing- 
ton, No. 201, 1914. 



66 ENERGY METABOLISM 

scientific value since the composition of the food varies even when 
the greatest precautions are taken to keep it uniform. It is of 
value only to the clinician in his practical work and may give false 
information. 

Howland, working in Professor Lusk's Laboratory at Cornell 
University Medical School, showed in a very brilliant way that 
the output of heat when measured directly and when computed 
from the carbon dioxid and oxygen, coincided very closely. The 
greatest difference was two per cent. Other investigations, in 
which the heat was computed from the carbon dioxid and oxygen, 
are, therefore, within very small limits of error. 

The Effect of Muscular Exercise on Metabolism. — Schloss- 
mann appreciated the fact that muscular exercise caused a marked 
increase in the heat production of an infant. Howland found a 
difference of 17.6% and 39% in the heat production between 
periods of quite sleep and active struggling and crying, while 
Murlin and Hoobler found that hard crying may increase the 
metabolism as much as 40%. Benedict and Talbot found that an 
increase of 60% was common and that there could be an increase 
of 100% (as in the case D Q Dec. 22 *) from quiet sleep to active 
exercise. It is obvious, therefore, that a comparison of the metab- 
olism of an active healthy infant with that of a quiet sick infant 
is of no value, because in one the effect of muscular activity is 
added to the basal metabolism and in the other it is not. The 
basal metabolism, that is, the metabolism during complete mus- 
cular repose, should be always used when health and disease are 
compared. 

The Effect of Fasting on the Metabolism. — There is evidence 
which seems to show that the metabolism of infants after taking 
food is always higher than it is in the same infant while fasting. 2 
Howland, 3 in commenting on one of his experiments says: "This 
experiment, so far as one can do so, brings additional proof to the 
view that insufficient food reduces the carbon dioxid excretion, 
but that after eighteen hours, a fasting metabolism is not reached 
with infants, as shown by the normal heat production and by the 
respiratory quotient of 0.81. " Schlossmann and Murschhauser 2 
found that after eighteen hours of fasting acetone soon appears 
in the urine in considerable quantities. The question can be 
raised, therefore, whether an infant, which has been starved more 

1 Benedict and Talbot: Carnegie Institution of Washington, Pub. 201, p. 97. 

2 Schlossmann and Murschhauser: See Murschhauser, Boston Med. and 
Surg. Jour., 1914, clxxi, 185. 

3 Howland: Tr. Fifteenth Internat. Cong. Hyg. and Demog., 1912, ii, 438. 



ENERGY METABOLISM 67 

than twenty-four hours and whose urine contains considerable 
quantities of acetone, can be considered normal. Benedict and 
Talbot 1 studied the fasting metabolism of several infants at periods 
from three to twenty-four hours after food had been given. They 
found that the respiratory quotient was markedly lowered after 
eighteen hours of fasting. The figures of heat production obtained 
were inconsistent, because it was almost impossible to obtain half 
hour periods for study in which the fasting infant was in complete 
muscular repose. If the metabolism is lower after eighteen or 
twenty-four hours' fast than it is directly after taking food, it must 
be only slightly diminished. Further investigations must be car- 
ried on to decide at which point the metabolism of a fasting infant 
changes from a physiological condition into a pathological condi- 
tion. For this reason recent investigations have been confined 
almost entirely to measuring the metabolism directly after food 
has been given. 

Comparison of Body Surface and Metabolism. — For many 
years writers on metabolism have been wont to emphasize the sig- 
nificance of the relationship supposed to exist between the metab- 
olism and the body surface rather than that between the metab- 
olism and the body weight. The idea that there is an intimate 
relationship between body surface and heat production was first 
brought out by Bergmann 2 in 1847. The theory lay dormant 
for many years, but was finally resuscitated and put forth in a 
brilliant and highly stimulating manner by Rubner 3 in 1883, to- 
gether with experimental evidence. Based fundamentally on New- 
ton's law of cooling, it received great attention from practically all 
workers in physiology. The startling evidence which was brought 
forward to demonstrate that the heat production per square 
meter of body surface was about 1,000 calories for practically 
all species of animals lent further support to this hypothesis. 

The researches of Benedict and Talbot, 4 confirmed by Murlin 
and Hoobler, 5 show that such conclusions are not warranted in 
infancy since the relation between the basal metabolism of in- 
fants and the body surface is not uniform. 6 The following chart 
illustrates this point : 

1 Benedict and Talbot: Carnegie Institution of Wash., Pub. 201. 

2 Bergmann and Leuckart: Anatomisch-physiol. Uebersicht des Thierreichs, 
Stuttgart, 1852, 272; Bergmann: Warmedkonomie der Thiere, Gottingen, 
1848, 9. 

3 Rubner: Ztschr. f. Biol., 1883, xix, 545. 

4 Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 
6 Murlin and Hoobler: Am. Jour. Dis. Children, 1915, ix, 81. 

• Lusk and others consider that there is a very definite relation between 



68 



ENERGY METABOLISM 



CHART I (Benedict and Talbot) * 

Chart showing actual body weight of infants and heat production per square 
meter of body-surface (Meeh formula) per twenty-four hours 

HEAT PER SQUARE METER (MEEH) PER 24 HOURS 



9.0 
8.0 
7.0 
6.0 
5.0 
4.0 
8.0 
2.0 

625 575 625 675 725 775 













HT 

• 




EG* 


RS» 






































EK 




















EF 












RL 

• 

PW. 
























AS 




RA 

MC • 

• 


ND* 






PS» 












EM 

• 










MM. 

LL • 




LRB 

DO. 


RE . 


• 
MA . 
EN 


BF 


JP 
• 
• DM 








• 

JM 






UH 


RC 

• 


FR 

• 






BO- 


ER» 


• FD 
LB 


WP. 


• 

• JS 
EL» 


• 
TC 


• 

FB 












TK< 

RD» 


oc 


MD* 


IR- 




GS 


KR ■"» * 

• • 


JO 

L AD 

m 


•EC 


LO 

• 


SM* • 

. FM 

HC 


• 
JV 


8 V 2 MOS. 












AC - 






•ehs 




ES 


































JV s'/j 


<os. 



















875 925 975 1025 1075 1125 J175 1225 1275 1325 1375. 
CALORIES 



This chart shows that the basal metabolism per square meter 
of body surface varies over 100%, when new-born infants, viz., 
those lying to the left on the line marked 675 calories are 
included. Benedict and Talbot x conclude, — "that our evidence 
points strongly and conclusively to the fact that the active 
mass of protoplasmic tissue determines the fundamental metab- 
olism. The absence as yet of a direct mathematical measure of 
the proportion of active protoplasmic tissue does not, we believe, 
in any wise affect the convincing nature of our evidence." 

The total basal metabolism of an infant increases with its age 
and weight, as would be expected. On the following chart, taken 
from the paper by Benedict and Talbot, 1 the normal infants are 
indicated by crosses and the abnormal infants, including those that 
are under-weight, are indicated by dots. A hypothetical curve 
has been constructed for the normals that shows the tendency 
of the metabolism to increase with the weights of the infant. In 
general, those infants which weigh more than the average for the 

the metabolism of adults and their body surface. There is a much closer 
agreement between the figures when the body surface is measured by the 
Du Bois formula which is the most accurate. 

1 Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 



ENERGY METABOLISM 



69 



age lie above the curve while those which weigh less than the aver- 
age fall below the curve. 

CHART II 

Chart showing the actual body weight of infants and the total heat produc- 
tion per twenty-four hours 

TOTAL HEAT PER 24 HOURS 



9.2 



8.4 



0)6.8 

8 

x. 

£6.0 
o 

hi 

^5.2 



3.6 



2.0 





















HT 

X 




EG 

X 




X R3 






















































•EK 














EF* 










RL 
XPW 


















AS 


y^«c 


RA» 


NO 




PS* 






EM 

• 












MM DO 


LRB 


•MA 

•em 


FK.BF 






•jM 










FR^X 




ER» 


FD* 


•RE 

•CN 

• JS 


DM* 
• 
• FB 
TC 














TKs 


RC 


*V 




LB . 

EC 

• 


• 
EL 

GM '.FM 


















AC» 


* 

oc 

EHS. 


KR» J[ 


>L J °' 

••ao 


HC* 
LO 


JV %\\ 


ios. 












































• 


3 1 / 2 MOS. 



























135 165 



195 



255 285 



405 



= NORMAL INFANTS 

= ABNORMAL INFANTS INCLUDING THOSE UNDERWEIGHT 



The comparison of the basal heat production per kilogram of 
body weight is of more practical interest to the clinician. 

Chart III on the next page is taken from the paper of Benedict 
and Talbot. 

In general, the babies weighing the average for the age and in all 
respects normal fall between the lines marked A and B or, roughly 
their basal metabolism is between 52 and 63 calories per kilogram 
of body weight. The normal infants, other than new-borns, that 
have a great deal of fat on their bodies in proportion to their muscu- 
lature, have a basal metabolism of between forty and a little more 
than fifty calories per kilogram of body weight. New-born infants 
are included in this class. Most of the infants that are under- weight 



70 



ENERGY METABOLISM 



CHART III 

Chart showing the actual body weight of infants and the heat production 
per kilogram per twenty-four hours 

HEAT PER KILOGRAM OF BODY-WEIGHT PER 24 HOURS 



9.0 



8.0 



7.0 

CD 
O 

^ 6.0 

X 

g 

Id 

§5.0 



3.0 









*RS 




















MT 




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EG 
























































EK 
























RL* 


















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PW 

• 
























• NO 






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• 






AS 


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MM | 










•fn 


JP i 












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• 






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ER 




"-B- 


WP 


• 


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UH 

TK 

rd" 


EP 

' IN* 

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• 


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jv sy 2 Mos. 








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50 A 



B 65 



80 



90 



have a basal metabolism of more than sixty-five calories per kilo- 
gram of body weight and, in general, the more they are under- 
weight, the greater is the basal metabolism. This chart shows 
that the basal metabolism per kilogram of body weight may 
vary 100% in different infants. There are some infants that 
are under-weight, whose vital functions are so depressed 
that their metabolism instead of being greater than the aver- 
age per kilogram of body weight, is less than the average. 
This is especially true of infants with subnormal temperatures, 
and may explain why some infants who have been very sick and 
as a result are weak, gain weight on surprisingly few calories. 

The Respiratory Quotient. — The respiratory quotient is the 
ratio between the volume of carbon dioxid expired and the volume 



ENERGY METABOLISM 71 

of oxygen inspired during the same time, viz., — ' = R. Q. 

vol. O2 

When carbohydrates are burned the respiratory quotient is unity, 
that is, for every hundred volumes of carbon dioxid excreted a 
hundred volumes of oxygen are absorbed. (The respiratory quo- 
tient for carbohydrates is 1.00.) The respiratory quotient for fat 
is 0.713 and for protein 0.801. The respiratory quotient, when 
carefully determined, throws considerable light on the character 
of the materials burned in the body. 

Caloric Values. — Rubner's "standard values" have been 
widely used throughout the world in determining the average fuel 
value of a mixed diet. They are: 

1 gram of protein 4.1 calories (large) 

1 gram of fat 9.3 calories (large) 

1 gram of carbohydrate 4.1 calories (large) 

The heats of combustion of the carbohydrates are as follows : 

Stohmann x Emery and Benedict 2 

Dextrose 3.692 3.739 

Lactose 3.877 3.737 

Saccharose 3.959 3.957 

Starch 4.116 

Since the carbohydrates used in infant feeding are usually sugars 
rather than starch, the caloric value of the carbohydrate would 
be more accurate if a lower factor were used, for instance, 3.7 for 
lactose. 

Computed Metabolism. 3 — The energy quotient is the term 
applied by Heubner 4 to the number of large calories per kilogram 
of body weight per day that are necessary for growth. The metab- 
olism of a large number of infants has been computed when the 
amount of fat, carbohydrate, or protein in the food was known, 
or in which averages of the various analyses of milk were taken. 
It has been shown by many investigators that the percentage com- 
position of human milk can vary within very wide limits, and ob- 
viously there must be a corresponding fluctuation in its caloric 
value. For this reason many of the computed energy quotients, 
based upon the average composition of human milk, are criti- 

1 Quoted by Lusk: The Science of Nutrition, Phila. and London, 1909, 41. 

2 Emery and Benedict: Am. Jour. Phys., 1911, xxviii, 301. Later they 
showed even a greater difference in the heat of combustion of lactose. 

3 An excellent review of the Continental work may be found in Frank : 
Engergiequotient und Temperatur im Saulingsalter. Inaug. Dissert. Munchen, 
1913. 

4 Heubner: Kinderh., 3 auflage, Leipzig, 1911, vol. I. 



72 ENERGY METABOLISM 

cised. Heubner * concluded that a breast-fed infant did not gain 
satisfactorily on human milk during the first three months when 
the energy quotient fell below one hundred calories, and that 
when the energy quotient fell below seventy calories there must 
be »a loss of weight. Schlossman 2 on the other hand found the 
best gain on an energy quotient of one hundred and ten calories. 
Premature infants and artificially-fed infants, according to Heub- 
ner, should have an energy quotient of not less than one hundred 
and twenty calories during the first three months of life. Feer 3 
found that the energy quotient of Baby Marianne, the composi- 
tion of whose food was known, during the thirty-third to the- 
forty-sixth week of life was between eighty-six and one hundred 
and four calories. He believes that the reason artificially-fed 
infants require more calories than the breast-fed is that the work 
of digestion is greater in the former than in the latter. Cramer 4 
studied the energy quotient of infants during the first nine days 
of life, and found a gain of from fifty to sixty grams with an en- 
ergy quotient of less than fifty calories. Gaus 5 confirmed these 
findings and it was concluded that there was a special metabolism 
for infants during the first two weeks of life. There is no doubt 
that the latter observations are true, and that during the first 
two weeks of life the caloric needs are very low. 6 

The caloric requirements then increase up to the third or 
fourth month at which time they are close to those given 
by Heubner. After that they diminish to the first year of life. 
Two infants, aged three and »six months respectively, studied 
at the Nutrition Laboratory of the Carnegie Institution of Wash- 
ington by Talbot 7 showed a metabolism of 100 and 94 calories 
respectively per kilogram of body weight. The metabolism of 
these two infants was measured during the whole of twenty-four 
hour periods with the exception of short periods in which they 
were removed for feeding. 

Siegert 8 concluded that it was possible for the breast-fed in- 
fant to gain on eighty calories per kilogram of body weight dur- 

1 Heubner: Jahrb. f. Kinderh., 1910, lxxii, 121. 

2 Schlossmann: Arch. f. Kinderh., 1902, xxxiii, 338. 

3 Feer: Lehrbuch der Kinderh., 2nd Ed., 1912. 

4 Cramer: Munch, med. Wochenschr., 1903, 2, L, 1153. 

5 Gaus: Jahrb. f. Kinderh., 1902, N. F. lv, 129. 

6 Benedict and Talbot: Physiology of the New-Born Infant: Carnegie Ins., 
Wash., Publication No. 233. Murlin and Bailey: Amer. Jour. Obstetrics 
and Dis. Women and Children, 1915, lxxi, No. 3. 

7 Talbot. Trans. Am. Ped. Soc, 1917, xxix. 39. 

8 Siegert: Versamml. d. Gesellsch., f. Kinderh., Stuttgart, 1906. 



ENERGY METABOLISM 73 

ing the first three months of life. Czerny and Keller 1 consid- 
ered Heubner's figures too high and report an infant of average 
weight (Machill) which gained regularly on an average of seventy 
calories per kilogram of body weight. A daily examination of the 
milk was not made. Bundin 2 f ed a number of infants on mix- 
tures of cow's milk which gave an energy quotient of seventy 
calories. These infants were of the average or of less than the 
average weight and gained weight consistently. Oppenheimer 3 
gave an energy quotient of one hundred and eleven calories to a 
normally developed infant and as high as one hundred and 
forty-two calories to an infant which had previously been underfed. 
Beck, in 1904, 4 collected the literature up to date and gives the 
following figures as an average energy quotient for breast-fed 
infants: 

1-12 weeks 107 calories 

13-24 weeks 91 calories 

25-36 weeks 83 calories 

37-44 weeks 69 calories 

He concluded that artificially-fed and premature infants re- 
quired an energy quotient of from one hundred and twenty to one 
hundred and forty calories. Ladd 5 gave an energy quotient which 
varies between ninety-three and one hundred and fifty-nine cal- 
ories. Dennett 6 concluded that the average normal baby will do 
well on from one hundred and ten to one hundred and twenty cal- 
ories per kilogram and that very emaciated babies require from one 
hundred and sixty to one hundred and seventy calories, while 
those who are only moderately emaciated require from one hun- 
dred and thirty to one hundred and fifty calories. Finally, Fink- 
elstein, 7 Gittings, 8 and Mayerhofer and Roth 9 drew attention to 
the fact that infants who were under-weight required more calo- 
ries than well-developed infants and advanced the suggestion that 
they require as many calories as they would need if they had de- 
veloped in the normal manner. 

1 Czerny and Keller: Des Kindes Ernahrung, Emahrungsstorungen, und 
Erhahrungstherapie, Leipzig and Wien, 1906, vol. i, 396. 
3 Bundin: See Czerny and Keller, p. 404. 

3 Oppenheimer: Arch. f. Kinderh., 1909, L. 355. 

4 Beck: Monatsschr. f. Kinderh., 1904-05, iii, 206. 
6 Ladd: Archives of Pediatrics, 1908, xxv, 178. 

6 Dennett: Trans. Section on Dis. of Children, Amer. Med. Asso., 1912, 186. 

7 Finkelstein : Lehrbuch der Sauglingskrankheiten, 1905, i, 54. 

8 Gittings: Am. Pediatric Soc, Stockbridge, 1914, Reported in Jour. A. M. 
A., 1914, lxiii, 55. 

9 Mayerhofer and Roth: Zeitschr. f. Kinderh., 1914, xi, 117. 



74 ENERGY METABOLISM 

The figures just given as to the clinical status of the caloric 
requirements of different infants show what a difference of opinion 
there is among the various authorities. There can be little doubt 
that in the main they are all correct, if one bears in mind the pos- 
sibility of error in such rough calculations of the energy metabo- 
lism of infants. Unfortunately, the accurate measurement of the 
energy metabolism in the calorimeter or by the respiratory ex- 
change is only for shorter or longer periods of the twenty-four 
hour day and does not give exact measurements of the twenty- 
four hour metabolism. It is necessary, therefore, to depend upon 
the knowledge of the basal metabolism of a large number of in- 
fants and to attempt to correlate this with the results of clinical 
experience. 

The metabolism of the new-born infant has been recently 
studied anew. 1 After birth there is a loss of weight which is due 
to two distinct causes : — 

1. Mechanical. 

2. Physiological. 

The former is due to loss of meconium, urine and vomited ma- 
terial, while the latter is due to actual loss of body substance 
as a result of metabolism. The colostrum does not supply 
enough food for the infant in the first three days of life, before 
the breast milk " comes in"; the body substance, therefore, has 
to supply what is necessary for the infant's vital functions. 
The respiratory quotients show that during the first few hours 
of life the supply of glycogen and sugar in the body is quickly 
exhausted, and that the body must then subsist on its own fat. 
This it does until the body gets enough breast milk to supply 
the necessary food. There is also a distinct correlation be- 
tween the body temperature and the general metabolism, for 
when the temperature is subnormal, the metabolism is low, in- 
dicating that all the vital functions are below par. The usual 
cause of the subnormal temperature was chilling from the tub 
bath or exposure. This may be distinctly dangerous to life. The 
average basal metabolism of the new-born infant from V/2 to 6 
days of life is 44 calories per kilogram of body weight, and it is 
estimated that the new-born infant requires 62 calories per kilo- 
gram of body weight in its food. These findings teach us that 
all precautions should be taken against exposure after birth, that 
the water cleansing bath may be dangerous to life and should, 
therefore, not be used, but in its place a warm oil bath may be 

1 Bailey and Murlin: loc. cit. (6 infants); Benedict and Talbot, loc. tit. 
(104 infants). 






ENERGY METABOLISM 75 

given; that before the mother's milk "comes in" the baby does 
not get sufficient food, and, therefore, a sugar and water solution 
should be given to partly make up the deficit. A solution of 5% 
lactose proves very satisfactory. 

Metabolism During Starvation. — Very few observations have 
been made on the metabolism during fasting, and nearly all of 
our knowledge comes from the work of Schlossmann and Mur- 
schhauser l in the Dusseldorf Clinic on normal infants. They 
found that there was always an increased nitrogen elimination 
from the body in both the infant that had been artificially fed 
or breast fed. The total amount lost was greater in the former than 
in the latter. Less nitrogen was lost if lactose were given the 
infant even in small quantities. The blood sugar remained nor- 
mal until near the end of a seventy-two hour fast when there was 
a slight fall. After twelve hours of fast, acetone bodies appeared 
in the urine and increased in amount in the same manner as during 
adult fasting. The excretion of acetone bodies was entirely pre- 
vented by giving 70 grams of lactose in the day. 

Summary. — The basal metabolism of an infant is the metab- 
olism determined after the taking of food, with the infant in 
complete muscular repose. Comparison of infants in different 
states of nutrition shows that roughly the normal new-born infant 
has a basal metabolism of 44 calories per kilogram of body weight, 
while that of the older infant is about 55 to 60 calories per kilo- 
gram of body weight. This is the lowest amount of energy on 
which a baby can maintain its body functions. The habits of 
healthy infants vary with the individual. One is phlegmatic and 
sleeps most of the day and night, while another is moving, kick- 
ing or crying during most of its waking hours. It has been shown 
that the metabolism may be increased from forty to one hundred 
per cent above the basal metabolism by the change from complete 
muscular repose to active exercise. It seems probable, therefore, 
that the infants studied by Czerny, Budin and their followers were 
placid infants who conserved their energy for development, and 
that Heubner and his followers dealt with more active infants. 
It is necessary to add certain factors to the calories found for the 
basal metabolism for muscular exercise, for loss of energy in the 
feces, and for growth. These can only be estimated by studying 
the habits of a given infant. The consensus of opinion seems to 
be that breast-fed infants require less energy than the artificially- 
fed, because less energy is required to make the food available for 

1 Schlossmann and Murschhauser: Biochem. Zeitschr., 1913, lvi, 335; 
Schlossmann: Biochem. Zeitschr., 1914, lviii, 493. 



76 ENERGY METABOLISM 

the body. This may be the sole explanation, or it may be that the 
difference in their requirements is due to the fact that the breast- 
fed infant is on the average a quieter infant and that it sleeps 
more than the artificially-fed infant. 

Babies that weigh more than the average weight for their age 
and new-born infants have usually a basal metabolism of between 
forty and fifty-two calories per kilogram of body weight. Both the 
new-born and fat infants are quieter than infants which have 
developed their muscles and as a result the energy required for 
muscular work, which must be added to their basal energy metab- 
olism, is less than it is in active, crying infants. The large fat 
babies which weigh more than the average will, therefore, gain 
more weight on a low energy quotient than babies of average 
weight. The new-born infant falls into this class as it has a rela- 
tively large proportion of fat and a small proportion of muscle. 

Moderately emaciated or atrophic infants have a higher basal 
metabolism than do the babies of average weight. It varies be- 
tween sixty-three and eighty-seven calories per kilogram of body 
weight. When the energy required for muscular work is added to 
this, the energy quotient is the result. It must be remembered, 
however, that infants of this type that have many loose undigested 
stools may lose twenty per cent * or more of the energy of the food. 
Some under- weight infants require many more than the 120 calories 
per kilogram of body weight, which is considered the high normal 
figure. If the infant is very weak and quiet, a small increase in 
the number of calories above the basal requirements will be suffi- 
cient to enable it to gain in weight. If, on the other hand, it is 
crying from morning to night because of either hunger or dis- 
comfort, a very much greater percentage of calories must be added 
to the basal requirements in order that it may grow. There laso 
can be little doubt that in weak babies energy, which would other- 
wise be used to keep the baby warm, can be conserved by increas- 
ing the temperature of the infant's surroundings. The infant that 
is under-weight requires, therefore, somewhere between one hun- 
dred and thirty and one hundred and sixty calories per kilogram 
of body weight. The normal new-born infant requires approxi- 
mately 62 calories per kilogram of body weight. The energy 
requirement increases in the first quarter year up to between 
100 and 120 calories and then gradually falls so that at the end 
of the first year the normal infant needs between 70 and 80 cal- 
ories per kilogram of body weight. These figures are modified 
by the individual peculiarities of the infant. 

1 Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 






CHAPTER VII 
BACTERIOLOGY OF THE GASTROINTESTINAL CANAL 1 

BACTERIOLOGY OF THE MOUTH 

The infant's mouth is sterile before birth, but becomes infected 
from the mother's vagina during birth, 2 or from the air soon 
after birth. 3 The variety of organisms present at this time is 
relatively small, but as soon as the infant commences to take 
food the flora becomes more complicated. The number of bac- 
teria does not, however, increase materially. When the infant 
takes breast milk, there is an increase in the variety of the or- 
ganisms, and pathological bacteria even may be found in the 
mouths of healthy babies. 4 Because of the fact that even the 
purest cow's milk contains more bacteria than human milk it is 
reasonable to expect that the mouths of babies fed on the bottle 
will contain a greater variety of bacteria than those fed at the 
breast and that the dirtier the milk the greater will be the variety of 
the organisms. There are, however, no data as to whether this is 
true or not. After the eruption of teeth, i. e., after the infant is six 
months old, the number and variety of the bacteria increase 5 and 
certain microorganisms, such as the Leptothrix, 6 and fusiform 
bacteria, 7 which are apparently only able to obtain a foothold in 
the mouth when teeth are present, 8 appear. 

It is an open question as to how important a part the bacteria of 

1 G. • Bessau in Tobler, Allegemeine Pathologische Physiologie der Er- 
nahrung und des Stoffwechsels im Kindesalter, Wiesbaden, 1914, has been 
freely used in this chapter and many of the statements have been taken 
directly from it. It may be consulted by those who wish to go into the subject 
more deeply. 

2 Kneise: Sittler quoted by Tobler. 

3 Campo: La Pediatria, 1899, vii, 229. 

4 Doernberger: Jahrb. f. Kinderh., 1893, xxxv, 395; Herzberg: Deutch. 
med. Woch., 1903, xxix, 17. 

5 Noblecourt and Vicaris: Arch. gen. de Med., 1905, 2, 3201, ref. Monats- 
schr. f. Kinderh., 1905-6, iv, 640. 

6 Oshima: Arch. f. Kinderh., 1907, xlv, 21. 

'Uffenheimer: Munch, med. Woch., 1904, 1198, 1253; Ergebnisse d. inn. 
Med. u. Kinderh., 1908, ii, 304. 

8 For a more detailed account of the flora of the mouth E. Kuster in Kolle 
Wasserman's Handbuch, II ed., Jena, 1913, vi, 435, may be consulted. 

77 



78 BACTERIOLOGY 

the mouth play in the digestion processes in the stomach. It is 
conceivable that these bacteria, especially when there is dental 
caries, may do harm. It has not been proven, however, that they 
do. 

BACTERIOLOGY OF THE STOMACH 

The same influences which modify the bacterial flora of the 
mouth modify that of the stomach. Under physiological con- 
ditions the bacteria in the stomach play an unimportant role. 
A description of the individual kinds may be found in the works 
of Escherich * who was a pioneer in this field of investigation. 
The smallest numbers are found in the stomachs of the breast- 
fed, 2 and they remain relatively scarce as long as the digestion 
is normal. When there is indigestion, there is an increase in 
their numbers. The greatest numbers are found in cholera in- 
fantum. 3 

Bactericidal Powers of the Stomach. — Free hydrochloric acid 
is able to destroy bacteria in the stomach. 4 There is no doubt 
that it is strongly attracted by the proteins of the food and quickly 
combines with them, thus becoming inert. Furthermore, the casein 
in the milk is rapidly coagulated into curds. The disinfecting 
action of the hydrochloric acid can only be effective on the sur- 
face of the curds, and the large numbers of bacteria which are 
present in the interior of the curds are not reached by it. 5 The 
number of bacteria in the stomach apparently depends also on 
the activity of the gastric motility, for the quicker the stomach 
is emptied, the fewer are the bacteria which it contains. The 
converse is also true. 

Lactic acid fermentation does not seem to play as important a 
part in the stomach of the infant as it does in that of the adult in 
which it occurs only when hydrochloric acid is absent. Lactic acid 
is seldom or never found in the stomach of the breast-fed, but is fre- 
quently found in small amounts in the stomachs of infants fed on 
cow's milk. 5 

Butyric acid fermentation is more common, 6 and has been 
found to occur in the stomachs of atrophic infants in which the ex- 
cretion of hydrochloric acid and the motility are both diminished. 

1 Escherich: Die Darmbakterien des Sauglings, Stuttgart, 1886. 

2 Van Puteren: Ref. Zeitschr. f. mikroskopie, 1888, v, 539. 

3 Seiffert: Jahrb. f. Kinderh., 1891, xxxii, 392. 

4 Hamburger: Ueber die Wirkung des Magensaftes auf pathogene Bakterien. 
Inaug. Diss. Breslau, 1890, quoted by Tobler. 

5 Tobler: Ergeb. d. inn. Med. u. Kinderh., 1908, i, 495. 
8 Cassel: Arch. f. Kinderh., 1890, xii, 175. 



BACTERIOLOGY 79 

The pasteurization or boiling of milk destroys the organisms which 
produce lactic acid but does not kill the spore-bearing bacilli, 1 
which produce butyric acid. The latter causes the formation of 
butyric acid from carbohydrates and fat and possibly from protein. 
Whether butyric acid is formed or not depends, according to Tob- 
ler, not on the kind of food present, but on the type of bacteria. 
This may be in part true, because fermentation cannot take place 
without fermentative organisms. On the other hand, however, 
the food components necessary for fermentation must be present 
in sufficient quantity to supply the bacteria with fermentable 
material. The lactic acid bacilli and the butyric acid bacilli are 
the only organisms which usually play a part in the various proc- 
esses of acid production in the stomach. The other bacteria (B. 
bifidus, B. acidophilus, B. coli and B. lactis aerogenes), which 
form acid are usually found only in the lower intestinal canal. 

BACTERIOLOGY OF THE UPPER PART OF THE SMALL INTESTINE 

The upper part of the small intestine, in comparison with the 
rest of the digestive canal, is relatively free from bacteria, both in 
the breast and in the bottle-fed infant, especially during fasting. 
Hess 2 studied the bacteria of the duodenum during life by an 
ingeniously devised modification of his duodenal catheter. He 
found that in the new-born infants, who had received no food, 
the duodenum contained very few organisms, only from one to 
three growing on a plate. The organisms were staphylococci, 
Gram positive and Gram negative bacilli. Colon bacilli were 
not found. Infants in the first week of life also had very few 
bacteria in the duodenum and these were of the same varieties as 
those found soon after birth. There was more or less similarity 
between the bacteria of the stomach and the duodenum. The 
staphylococcus was the organism most frequently found at this 
age. Hess could not establish any relation between the amount 
of hydrochloric acid in the stomach, or of bile in the duodenum, 
and the number of bacteria. The presence or absence of icterus 
made no difference in the bacteriology of the duodenum in these 
babies. Cultures from the duodenal contents of older breast-fed 
babies showed from one hundred to two hundred colonies per 
plate. The plate method would not be satisfactory for an aero- 

1 (Bodkin's butyric acid bacillus appears to be relatively rare and it is possi- 
ble that the gas-bacillus, which also forms butyric acid, is the one that is 
ordinarily found.) 

2 Hess: Ergebnisse der inn. Med. u. Kinderh., 1914, xiii, p. 530. 



80 BACTERIOLOGY 

bic organism such as the bacillus bifidus, which may also be 
found in this region. It must be remembered, therefore, that 
these results may not represent the true condition. Those from 
bottle-fed infants showed many more. 1 

There is evidence that, while the duodenum may be practically 
free from bacteria during the intervals between digestion, there 
is a relatively large population in the small intestine while the food 
is passing through it. 2 According to Ficker 3 and Moro 4 the flora 
of the upper small intestine is composed principally of short Gram 
negative rods (colon bacillus and bacillus lactis aerogenes) with 
an occasional isolated bacillus bifidus communis, bacillus acido- 
philus and butyric acid bacillus, and enterococci. 

Moro 5 believes that there can be an endogenous infection of 
the small intestine. Such an infection is probably present in most 
disturbances of nutrition, both acute and chronic. The epidemic 
of severe diarrhea, associated with the presence of inflammatory 
products in the stools (blood and pus), described by Escherich 6 
has been used as evidence for this point of view. The infants 
attacked were all young, their ages varying from four to ten 
months. The stools contained bacteria, which he called "blaue 
Bacillose" and which were proved to be, almost without question, 
"aciduric" 7 or acidophilic organisms. These organisms were 
probably identical with those which are normally present among 
the flora of the healthy nursling. Logan 8 on the other hand was 
unable to show that any colon-like organisms from cases with 
diarrhea showed any greater virulence to guinea pigs than the 
same organisms from babies not suffering from diarrhea. 

BACTERIOLOGY OF THE LOWER PART OF THE SMALL INTESTINE AND 
OF THE LARGE INTESTINE 

There are relatively fewer bacteria in the healthy small intes- 
tine down to the lower part of the ileum. There they begin to 
increase in number so that when the large intestine is reached 

1 Moro; Jahrb. f. Kinderh., 1905, lxi, 870, may be consulted for the litera- 
ture. 

2 Moro: Arch. f. Kinderh., 1906, xliii, 340; Kohlbrugge: Cent. f. Bact., 
Orig. 1901, xxix, 571; Landsberger: Diss. Konigsberg, 1903, quoted by Kendall. 

3 Ficker: Arch. f. Hyg., 1905, liv. 354. 

4 Moro: Arch. f. Kinderh., 1906, xliii. 

5 Moro: Munchen. Gesellsch. f. Kinderh., 1907, xi, 15. 

6 Escherich: Jahrb. f. Kinderh., 1900, 52, 1. 

7 Kendall: Jour. Med. Research, 1911, xx, 117. 

8 Logan: Jour. Path, and Bact., 1914, xviii, 527. 



BACTERIOLOGY OF STOOLS 81 

they are very numerous. The types of bacteria which are com- 
monly found, according to Kendall, are as follows: 1 The more 
commonly recognized bacteria are the B. bifidus (Tissier), the 
Mic. ovalis, the B. coli, the B. lactis aerogenes, and the B. acido- 
philus (Moro) . These make up the fecal flora of the normal nurs- 
ling. The B. lactis aerogenes appears in the upper levels of the 
tract, that is, the duodenum and jejunum; the Mic. ovalis in the 
lower jejunum and in the ileum to the ileocecal valve; the B. coli 
and the B. acidophilus in the region of the ileocecal valve, while 
the B. bifidus appears to dominate the ascending and transverse 
colon. This cannot be accepted without reservation since intes- 
tinal bacteriology is by no means so simple as it would appear from 
the foregoing statement. The remainder of the tract to the anus 
is relatively poorly populated in relation to the ccecum so far as 
living bacteria are concerned. This is due in part to the consid- 
erable degree of desiccation of the fecal contents of the intestines 
and in part to the accumulation of waste products, which appear 
to inhibit the development of bacteria. 

The character of the bacteria in the large intestine depends 
largely upon the food, 2 and, since human milk is a relatively homo- 
geneous food, the tendency of the bacteriological flora of the breast- 
fed is toward uniformity. The bacteriological conditions in the 
artificially fed are, as would be expected, less consistent, because 
there is less uniformity in the food which they receive, and because 
cow's milk is rarely sterile. The distinctive features of the stools 
of the artificially fed are the relative increase of Gram negative 
bacilli of the colon-aerogenes type and of cecal forms of the Mic. 
ovalis types. Coincidently, there is a decrease in the number of 
organisms of the B. bifidus type. The B. acidophilus is relatively 
more numerous and the B. bifidus less numerous. 



BACTERIOLOGY OF THE STOOLS 

The first stools (meconium), of the new-born are sterile, but 
they become infected shortly after birth. Within eighteen to 
twenty-four hours after birth, bacteria make their appearance 
in the stools and the meconium begins to disappear. The kinds 
and the number of bacteria which are found depend largely upon 
the season and the environment of the infant. 3 This is a period 
of mixed infection. The following organisms have been found 

1 Kendall: Jour. Med. Research, 1911-12, xx, 117. 

2 Moro: loc. cit. 

3 Kendall: Wisconsin Med. Jour., 1913, xii, No. 1. 



82 BACTERIOLOGY OF STOOLS 

in meconium: B. subtilis, B. coli, 1 B. bifidus, B. putrificus (Bien- 
stock), butyric acid bacillus, 2 and enterococci. 3 These organisms 
undoubtedly gain entrance to the intestinal canal through both 
the mouth and the anus. Meconium is a poor culture medium, 
probably because of its small water content. 

The B. bifidus appears about the beginning of the third day and 
persists throughout the nursing period. It is an obligate anaerobe 
(Kendall), Gram positive, and is the most characteristic organism 
of the nursling's stool. It is apparently independent of the quality 
of the stool and is present in the classical golden-yellow, homog- 
eneous, pasty stool as well as in those which deviate from this 
character in consistency and color. 4 Although the B. bifidus dom- 
inates the typical field, other Gram positive bacteria can always 
be found. Other bacteria that have been described in the stools 
of the nursling are cocci, the B. lactis aerogenes, the B. coli, the 
B. acidophilus, butyric acid bacillus, the B. mesentericus and the 
B. aerogenes capsulatus (Welch). 

The bacteriology of the stools of the artificially-fed infant is 
much more complicated than that of the breast-fed. No charac- 
teristic type of bacteria predominates, but there is a mixture of 
bacterial types. Culturally, the same species are found as in the 
stools of the breast-fed infant. The general picture is, however, 
apt to be Gram negative in contradistinction to that of the stool 
of the breast-fed infant, which is usually Gram positive. The 
B. coli communis, and the B. lactis aerogenes are the most numer- 
ous of these predominating Gram negative bacteria. A peptoniz- 
ing bacillus, which is almost always absent from the stools of the 
breast-fed, has been recorded by Rodella. 5 Passini 6 found these 
types of butyric acid forming organisms, and isolated peptonizing 
organisms from the stools of apparently normal bottle-fed babies. 
The B. putrificus, the most typical example of a purely proteolytic 
organism, has been found in several cases. 

The discussion as to the causes which influence the appearance 
and disappearance of certain bacteria is of more than polemic in- 
terest, since it may lead to some conclusions which will have a 
practical application. Kendall's 7 view is given as follows: "The 
intestinal tract is sterile at birth, because the uterine cavity is 

1 Escherich: loc. cit. 

2 Moro: Jahrb. f. Kinderh., 1905, bri, 885. 

3 Sittler: Habititationsschr., Wurzburg, 1909, quoted by Tobler. 

4 Moro: Jahrb. f. Kinderh., 1905, hri, 687. 

6 Rodella: Zeits. f. Hyg., 1902, xli, 466. 
•Passini: Zeits. f. Hyg., 1905, xlix, 135. 

7 Kendall: Wisconsin Med. Jour., 1913, xii, No. 1. 



BACTERIOLOGY OF STOOLS 83 

sterile. The first infection takes place adventitiously. Any 
organisms which enter by the mouth or through the anus in the 
bajbh water, which can exist at body temperature, may find lodg- 
ment in the intestinal tract and may temporarily grow there. 
Many of the bactera which thus succeed in entering the alimen- 
tary canal are spore-forming. During this period the food which 
is presented to them is largely detritus of fetal origin. At the 
beginning of the third day, when the breast milk has had a chance 
to throughly permeate the intestinal tract, new organisms appear, 
organisms which have a definite relationship to the type of food 
which is presented to them. It will be remembered that breast 
milk contains essentially 7% of lactose, about 3% of fat, and but 
1J^% of protein. Carbohydrate is, therefore, the dominant food. 
It is noteworthy that the organisms which appear in response 
to this diet are those whose metabolism is intimately associated 
with the utilization of sugar. These organisms thrive but poorly 
in a medium from which sugar is excluded. When other foods 
begin to replace the breast milk there is a definite change in the 
types of bacteria represented in the intestinal contents. The ob- 
ligate fermentative bacteria, such as the B. bifidus, are replaced 
by more plastic forms and by the B. coli which can accommodate 
their metabolism rapidly to dietary alterations. The B. coli for 
example can thrive equally well on a medium in which carbohy- 
drate is absent. It might appear from this rather definite altera- 
tion of types of bacteria in the intestinal tract following changes in 
the character of the food, that the food alone determined the 
intestinal flora. This may be somewhat influenced by the intes- 
tinal secretions. The essential feature, however, is the very direct 
relationship between the food and the bacterial reponse to it. This 
recognition of a relationship between food and bacteria in the intes- 
tinal tract is important in considering the intestinal flora, for it 
correlates the metabolism of the flora with the effects which it 
produces rather than attempting to establish indistinct relations 
between the morphology of the flora and these effects." These 
conclusions are supported by the work of Sittler, 1 and Bahrdt and 
Beifeld. 2 

Ford and Blackfan 3 produce evidence that "the bacteria with 
which the food is infected are almost the same as those found in 
the dejecta of the children fed on these foods." Sisson, however, 4 

1 Sittler: Centralbl. f. Bakteriol, 1908, xlvii, 14 and 145. 

2 Bahrdt and Beifeld: Jahrb. f. Kinderh., 1910, lxxii, Erganzungsheft, 71. 
8 Ford and Blackfan: Am. Jour. Dis. Ch., 1917, xiv, 354. 

4 Sisson: Am. Jour. Dis. Ch., 1917, xiii, 117. 



84 BACTERIOLOGY OF STOOLS 

was unable to cause any striking change in the intestinal flora 
of puppies by increasing the sugars in the food. Rettger, 1 found 
that by feeding lactose the B. .acidophilus and the B. bifidus 
became the predominating types. 

Bluhdorn 2 studied the intestinal flora of infants and found that 
greater acidity was formed in human milk than in cow's milk. 
He also found that lactose and maltose were more easily broken 
down by the intestinal flora of infants, than was cane sugar. Malt 
extract produced greater acidity than maltose. 

Further investigations are necessary to throw more light on the 
subject which is not as simple as it appears. It seems probable 
that other factors besides the sugar alone may play an important 
part in determining the intestinal flora, most important of which 
is the relation of the sugar to the other food components, especially 
those which favor putrefaction. 3 

It has been shown by Herter and Kendall 4 that when monkeys 
were fed on milk fermented with the bacillus bulgaricus it was 
possible to maintain an acid reaction throughout the intestinal 
tract, the acidity growing less marked below the ileocecal valve. 
After feeding the bacillus bulgaricus over a prolonged period, 
it may be found in large numbers in the small intestine, while 
only a very few can be demonstrated in the large intestine. Raehe 5 
showed that this organism cannot become adapted to the human 
large intestine. Rettger 6 concludes that "ingestion of foreign 
bacteria even in large numbers does not in itself bring about 
an elimination or displacement of the common intestinal micro- 
organisms. " 

It is interesting to note that Noguchi 7 in studying the growth 
and characteristics of the B. bifidus was able to transform it in 
the laboratory from the strictly anerobic type (B. bifidus, Tissier) 
to the facultative aerobic type (B. acidophilus, Moro) and back 
again to the anerobic type. Logan 8 believes that the B. bifidus 
of the breast-fed is replaced by the B. acidophilus in the bottle-fed. 

The Number of Bacteria in the Stools. — The most reliable 
figures as to the bacterial content of infants' stools are those ob- 

1 Rettger: Centralbl. f. Bacteriologie, 1914, lxxiii, 362, Jour. Exper. Med., 
1915, xxi, 365. 

3 Bluhdorn: Monat. f. Kinderh., 1915, xiii, 297. 

For a discussion of the action of the different sugars see Tobler. 

4 Herter and Kendall: Jour. Biol. Chem., 1908, v, 293. 

5 Raehe: Jour. Infect. Dis., 1915, xvi, 210. 

6 Rettger: loc. cit. 

7 Noguchi: Jour. Exper. Med., 1910, xii, 182. 

8 Logan: Jour. Path, and Bact., 1914, xviii, 527. 



BACTERIOLOGY OF STOOLS 



85 



tained by Strassburger's method. 1 This method is open to great 
sources of error. There is no suitable clinical method. He found 
that the bacterial content of infants' stools was as follows: 





TABLE 16 




Age 


Food 


Digestion 


Per cent of boxteria in 
the dried stool 


2 months 

m " 

5 

2 
1 


cow's milk 

It (I 

U (( 

human milk 
a it 


normal 

u 

? 

normal 
dyspeptic 


11.5 
42.3 
35.2 
25.8 
61.4 



Leschziner 2 found that 2% to 28.4% of the dried stool of the 
healthy breast-fed infant was composed of bacteria, while from 
6.52% to 29.4% of the total nitrogen was derived from bacteria. 
The newer and more perfect methods of Kramsztyk 3 and Klotz 4 
show that the number of fecal bacteria varies with the kind of 
food and that it is the chemical composition of the food rather 
than its bacterial content which is of significance. Escherich 5 
has shown that sterilization of the food has very little or no in- 
fluence on the number of fecal bacteria. 6 Kramsztyk found the 
smallest number in the stools of infants fed on the breast. He 
found more in the stools of those fed on diluted cow's milk, and 
most in the stools of those taking both human and cow's milk. 
Carbohydrates, especially in the form of malt extract, increase 
the number of bacteria. Klotz, whose figures are somewhat 
higher, found that the maximum amount of fecal bacteria in the 
dried feces is from 30% to 36%. He also found the smallest 
numbers in soap stools. Strassburger, however, found that 60% 
of the dyspeptic stool was made up of bacteria. Although count- 
ing the number of living bacteria is attended with many dif- 
ficulties there can be but little doubt that a large proportion of 
the fecal bacteria are dead. 7 

Pathogenic Bacteria. — The typhoid bacillus and the various 

1 Strassburger: Zeits. f. klin. Med., 1902, xlvi, 413. 

2 Leschziner: Deutsch. aerzte Zeitung, 1903, No. 17, 169. 

3 Kramsztyk: Zeits. f. Kinderh., 1911, i, 169. 

4 Klotz: Jahrb. f. Kinderh., 1911, lxxiii, 391. 

5 Escherich: Centralbl. f. Bacterid., 1887, ii, 633 and 664. 

6 For further literature consult Gerhard, Erg. d. Physiol. (Asber-Spiro 
1904, L. 107.) 

7 Eberle: Centralbl. f. Bacteriol., 1896, 19, 2. 



86 BACTERIOLOGY OF STOOLS 

types of paratyphoid bacilli may be present in the stools of infants 
under the same conditions as in adults. The same is true of the 
tubercle bacillus and the cholera bacillus, as well as of other un- 
common microorganisms, such as the bacillus of anthrax. 

The various types of the dysentery bacillus are frequently found 
in the infants. When these organisms are found in considerable 
numbers in association with the symptoms of disease of the intes- 
tinal tract, as in infectious diarrhea, they are, in most instances, 
the cause of the disease. Ten Broeck, 1 found the bacillus dys- 
enteriae of the mannite fermenting group in the circulating blood 
of an infant suffering with infectious diarrhea. Eleven negative 
findings in infants with infectious diarrhea lead him to conclude 
that the one positive finding was accidental rather than a usual 
feature of the disease. When large numbers of streptococci are 
found in association with fever and diarrhea it may be assumed 
that the streptococcus is the cause of the diarrhea. The presence 
of a few of these organisms in the stools in cases of diarrhea does 
not prove, however, that they are the cause of the symptoms. 
They also may sometimes be found in small numbers in the normal 
stools of apparently healthy infants. Under these circumstances 
they are to be regarded simply as saprophytes. 

Knox and Ford 2 concluded from their examinations of the stools 
that the gas bacillus is a constant inhabitant of the intestinal 
tract in all infants except those who are breast-fed. Ten Broeck 
and Norberry 3 came to similar conclusions, but do not give it the 
same etiological significance as does Kendall. 

1 Ten Broeck: Boston Med. & Surg. Jour., 1915, clxxiii, 284. 

2 Knox and Ford: Bull. Johns Hopkins Hosp., 1915, xxvi, p. 27. 

3 Ten Broeck and Norberry: Boston Med. & Surg. Jour., 1915, clxxiii, 280. 



CHAPTER VIII 
THE STOOLS IN INFANCY 

The examination of the stools is of the greatest aid in the diag- 
nosis of the nature of disturbances of digestion in infancy. It 
furnishes information which cannot be obtained so quickly and 
accurately in any other way. The clinical examination of the 
stools is, moreover, not a difficult matter. It requires but little 
time and but little apparatus. The methods are simple and easy 
to learn. It is fortunately not necessary to make use of the more 
complicated methods of analysis in every-day work, because the 
simple methods of clinical examination give information which 
is as useful for practical purposes as that furnished by the more 
accurate and elaborate procedures. 

The character of the stools depends primarily on the composi- 
tion of the food. It is modified by the digestive powers of the 
individual infant and by the amount and rapidity of absorption 
of the products of digestion. The amount of absorption depends 
to a considerable extent on the rapidity with which the intestinal 
contents pass through the intestinal tract. The character of the 
stools also depends on the nature of the bacterial flora of the in- 
testir_o. This is dependent, to a large extent, on the nature of the 
food. The influence which the bacteria exert depends largely on 
the digestive power of the infant and the rapidity with which the 
products of digestion are absorbed. The more feeble the digestive 
power and the slower the absorption, the greater the effect of the 
bacteria. It is often difficult, therefore, to draw conclusions from 
the examination of the stools as to just what is going on in the 
intestines. It is usually possible, however, to determine whether 
any given food element is properly digested and assimilated or 
not, and in many diseased conditions to tell what element is at 
fault. The presence of an improperly digested food element in 
the stools does not necessarily show, however, that this is the 
element primarily at fault, although it usually is. Fat curds may, 
for example, be present in the stools as the result of the fermenta- 
tion of sugar, the excessive peristalsis resulting from the irritation 
caused by the products of the fermentation of sugar preventing 
the proper absorption of the fat. When the element at fault is 

87 



88 STOOLS IN INFANCY 

known, it can be reduced and the necessary amount of the reduc- 
tion determined by repeated examination of the stools. 

meconium 

The meconium is dark brownish-green in color. The first me- 
conium passed is semi-solid, having been partially dried out in the 
large intestine. The remainder is more viscid. It is composed 
of mucus, bile, intestinal secretions and cells, with vernix caseosa, 
epithelial cells and hairs swallowed with the amniotic fluid. The 
meconium stools are replaced after from two to four days by stools 
composed of bile-tinged mucoid intestinal secretions. They are 
usually dark-green, but may be dark-brown or brownish-yellow, 
according to whether the bile pigment is in the form of bilirubin or 
biliverdin. The change to the normal fecal stool occurs gradually 
during the next two or three days. 

The stools of the breast-fed infant differ normally in their char- 
acteristics from those of the infant fed on cow's milk. The addi- 
tion of starch to cow's milk changes the character of the stools. 
The appearance of the stools varies also with the kind of sugar 
which is added to the milk. 

THE STOOLS OF BREAST-FED INFANTS 

During the first few weeks or months of lif e, the breast-fed infant 
has three or four stools daily. These are of about the consistency 
of pea soup and of a peculiar golden-yellow color. The odor is 
slightly sour or aromatic, and the reaction slightly acid. The 
number of stools gradually diminishes to two or three in the twenty- 
four hours and the consistency becomes more salve-like. The other 
characteristics are the same. The golden-yellow color is due to 
bilirubin, whicn, on account of the short time which it remains 
in the intestine, the relatively low protein content of the milk 
and the low reducing power of the infant's intestine, passes un- 
changed through the intestinal tract. The odor is due to a com- 
bination of lactic and fatty acids. The acid reaction is due to the 
relative excess of fat over protein in the milk. 

It is not uncommon for babies, even when they are thriving on 
the breast, to have a large number of stools of diminished con- 
sistency and of a brownish color. The examination of the breast- 
milk in such instances usually shows that the proteins are high. 
It is also not unusual to find many soft, fine curds, and some- 
times mucus in the stools of healthy breast-fed babies. Such 



STOOLS IN INFANCY 89 

stools are undoubtedly abnormal. It is unwise to pay too much 
attention to them, however, if the baby is gaining in weight and 
appears well. The breast-fed infant will often go weeks or months 
without a normal stool and yet thrive perfectly, while if a baby 
had such stools when it was taking cow's milk it would not thrive 
and would show distinct evidences of malnutrition. It is, there- 
fore, not only unnecessary, but distinctly wrong, to wean a baby 
simply because the stools are abnormal, if it is doing well in other 
ways. 

THE STOOLS OF INFANTS FED ON COW'S MILK 

Infants that are thriving on cow's milk mixtures have, as a gen- 
eral rule, fewer movements in the twenty-four hours than do breast- 
fed babies, and these movements are firmer in consistency. Slight 
constipation is not uncommon after the first months and is not 
pathological. The color of the stools is a lighter yellow. This is 
probably due in part to the relatively larger amount of protein and 
in part to the fact that some of the bilirubin is converted into hydro- 
bilirubin. When the relative proportions of fat and protein in the 
mixtures are approximately the same as they are in breast milk 
the odor and reaction of the stools are essentially the same as when 
the baby is taking breast milk. When infants are given whole 
cow's milk or simple dilutions of cow's milk, so that the percentage 
of protein is about the same as that of the fat, the odor is slightly 
modified toward the fecal or cheesy, because of the action of bac- 
teria on the casein. The reaction becomes alkaline for the same 
reason. 

Skimmed Milk Mixtures. — When infants are fed on skimmed 
milk or on mixtures containing very small percentages of fat and 
high percentages of protein, the stools have a slightly brownish- 
yellow color, a slightly cheesy or foul odor and a strongly alkaline 
reaction, because of the longer stay of the casein in the intestine 
and the consequently greater opportunity for bacterial action and 
for the change of bilirubin into hydrobilirubin. In most instances 
the stools have, when spread out, a peculiar, smooth, salve-like 
appearance like those from buttermilk. 

Whey and Whey Mixtures. — When infants are fed on whey 
or whey mixtures low in fat, the stools have essentially the same 
characteristics as those from skimmed milk, except that they are 
usually browner. Whey has a laxative action in many instances 
and sometimes has to be given up on this account. 

Starch Mixtures. — When starch is added to cow's milk mix- 
tures the color of the stools becomes more distinctly brownish and 



90 STOOLS IN INFANCY 

the reaction tends toward the acid. The odor is more aromatic. 
The source from which the starch is derived apparently has but 
little effect on the number of stools, although it is commonly 
thought that barley starch is constipating and oatmeal starch 
laxative. The action, if there is any, seems to vary with the in- 
dividual infant. It must not be forgotten in this connection that 
most starch flours contain small brownish specks which are the 
remains of the husks (cellulose). These specks pass through the 
gastrointestinal tract unaffected and appear in the stools. They 
are sometimes mistaken for intestinal sand or for dirt. 

Dextrin-Maltose Mixtures. — The addition of the various com- 
binations of the dextrins and maltose to cow's milk mixtures 
changes the color of the stools to a distinct brown, tends to make 
the reaction acid and to increase the acidity of the odor. These 
sugars usually have a laxative influence but sometimes constipate. 
In general, the higher the proportion of maltose, the greater is the 
laxative action. When these combinations of the dextrins and 
maltose, or the malted foods, which amount to the same thing, 
are given without milk, the stools are dark-brown, sticky, acrid 
in odor and acid in reaction. 

Buttermilk and Buttermilk Mixtures. — The stools of infants 
fed on buttermilk and buttermilk mixtures are of a peculiar 
shiny, salve-like appearance, grayish-brown or olive-green in 
color, alkaline in reaction and have a very characteristic acrid 
odor. 

Animal Food. — When beef juice or broth is added to the in- 
fant's diet the color of the stools is changed to brown, while the 
odor becomes fecal and the reaction alkaline from the action of 
bacteria on the proteins. It is not uncommon when babies are 
taking beef juice to have one portion of the stool brown with 
the remainder yellow, the dividing line between the two colors 
being very distinct. The dark color represents, of course, the meal 
at which the beef juice was taken. 

THE STARVATION STOOL 

The starvation stool is composed of bile, the intestinal secre- 
tions and bacteria. It resembles the meconium in appearance. 
It is small, and brownish or brownish-green in color. It is some- 
times constipated, sometimes loose. It usually has a stale odor 
like that of starch or paste. In some cases it has the odor of 
acetic acid as the result of action of microorganisms. It not in- 
frequently contains bile-stained mucus. 



STOOLS IN INFANCY 91 



REACTION OF THE STOOLS 



The reaction of the normal stool depends on the relation be- 
tween the fat and protein in the food. When there is a relative 
excess of fat the reaction is acid; when there is a relative excess 
of protein the reaction is alkaline, the reaction depending, in the 
one case, on the products of the decomposition of fat, in the other 
on the products of the decomposition of protein. The carbo- 
hydrates have but little effect on the reaction of the normal stool. 
When the carbohydrates are in excess, or when there is fermenta- 
tion of the carbohydrates as the result of bacterial action, the 
acidity of the stools is markedly increased. Stools which irritate 
the buttocks are invariably acid in reaction and in many instances 
this excessive acidity is due to the fermentation of carbohydrates. 
Frothy stools are usually acid in reaction and the result of the 
fermentation of carbohydrates. Sometimes, however, the frothi- 
ness is caused by gases formed during the decomposition of pro- 
tein. The reaction of the stools is best tested by placing wet 
red or blue litmus paper on a fresh surface of the stool. It is, how- 
ever, except when there is excessive acidity, of comparatively 
little importance clinically. 

ODOR OF THE STOOLS 

The odor of the stools depends on the composition of the food, 
the rapidity of the absorption of the products of digestion and the 
degree of the bacterial activity. The fats give the odor of butyric 
or lactic acid to the stools. The carbohydrates, if thoroughly 
utilized, do not affect the odor; if not utilized, they give the odors 
of lactic, acetic or succinic acids. The proteins give cheesy odors 
of various sorts, sometimes those of skatol, indol and phenol. 

The odor of the normal stool and the influence of variations 
in the diet upon it have already been mentioned. The stools of 
fat indigestion may have a strong odor of butyric acid, those of 
protein indigestion various cheesy or putrefactive odors as the 
result of the decomposition of the protein by bacteria. When 
several elements of the food are improperly digested the odor is a 
combination of those resulting from the decomposition of the va- 
rious elements. The stools of cholera infantum are almost odorless. 
Stools composed almost entirely of mucus have a peculiar aromatic 
odor resembling that of wet hay. When there are deep ulcerative 
or gangrenous processes in the intestine, the stools have a putrefac- 
tive or gangrenous odor. 



92 STOOLS IN INFANCY 



COLOR OF THE STOOLS 

The normal variations in the color of the stools according to 
the composition of the food have already been mentioned. Ab- 
normalities in the color are very common. The color of the stool 
must not be judged from the outside, as it may change very 
rapidly as the result of drying and exposure to the air. The stool 
must be broken up or smoothed out and the inside examined. 

Green. — The most common abnormal color is green. The shade 
of green may vary from a very delicate light grass-green to a 
dark spinach-green. In a general way, the darker the green, the 
greater its significance. When a stool is otherwise normal, a very 
light grass-green color is of no practical importance. The change 
from yellow to green after the stool is passed is not abnormal. 
The green color is, in the vast majority of instances, due to the 
change of bilirubin to biliverdin. There is much doubt as to the 
cause of this change. It is probable that it may be due to either 
excessive acidity or alkalinity of the intestinal contents or to the 
presence of some oxidizing ferment. The green color is not charac- 
teristic of any special type of disease. In some instances it is due 
to the action of the bacillus pyocyaneus. If it is due to bacterial 
action, the addition of nitric acid decolorizes the stool. If it is 
due to biliverdin, the addition of nitric acid gives the characteristic 
colors of Gmelin's test. 

Gray. — The next most common abnormal color is gray. This 
is due, as a rule, to the absence of bile and the presence of some 
form of fat, usually soap, in the stool. It must be remembered, 
however, that there may be bile in the stool even when it is gray, 
the bile pigment being in the form of the colorless leucohydrobili- 
rubin. It is never safe, therefore, to conclude that there is no bile 
in the stool without a chemical examination. The easiest and most 
satisfactory test is that with corrosive sublimate. This test is, 
however, not always accurate. When the stools are gray at birth 
or become so within a few days after birth, the lesion is usually a 
congenital obliteration of the bile ducts. It may be, however, an 
atresia of, or an obstruction in, the intestine. When the gray color 
appears later, and especially when it is associated with the pres- 
ence of large amounts of mucus, the trouble is usually in the 
duodenum. 

White. — White stools are composed chiefly of unabsorbed fat 
in the form of soaps. The white stools may be soft, looking like 
curdled milk or, more often, hard and dry, resembling the stools of 
a dog which has been eating bones. 



STOOLS IN INFANCY 93 

Black. — The black stool, while in rare instances due to the 
presence of changed blood, is usually due to the action of some 
drug. This drug is ordinarily bismuth, but sometimes iron or 
charcoal. In this connection it is well to remember that, when 
there is no sulphureted hydrogen in the intestine, bismuth may 
pass through the intestinal tract without being changed in color 
The administration of a grain or two of sulphur in the twenty- 
four hours will turn the stools black. Whether this is of any ad- 
vantage or not is questionable. 

Blue. — The stools are sometimes of a slaty-blue color. This 
color is due to some change in the bile pigments and is of no more 
significance than the green color. 

Pink. — It is very common to see a pink stain on the diapers 
about a stool which is otherwise normal or nearly so. This pink 
stain is of no especial significance and is due to some unknown 
change in the bile pigment. 

ABNORMAL CONSTITUENTS 

Curds. — The most common abnormal constituents of the stools 
are curds. There are two kinds of curds, one primarily composed 
of casein, the other composed mainly of fat, mostly in the form of 
fatty acids and soaps. The small amount of fat in the casein 
curds and the small amount of protein in the fat curds are merely 
incidents. The casein curds vary in size from that of a bean to 
that of a pecan nut. They are usually white, sometimes yellow in 
color. They are firm and tough, cannot be broken up by pressure, 
and sink in water. When placed in formalin they become as hard 
as rocks. They are insoluble in ether. The fat curds are small, 
varying in size from that of a pinhead to that of a small pea. They 
vary in color from white to yellow or green, according to the gen- 
eral color of the movement. They are easily broken up by pres- 
sure and when shaken up in water tend to remain in suspension. 
They are soluble in ether to a considerable extent after acidifica- 
tion and heating, and are unaffected by formalin. 

Mucus. — Mucus can be detected in small amounts under the 
microscope in the majority of normal stools and is almost invari- 
ably present in abnormal stools. It is never present macroscopic- 
ally in normal stools, but is very often visible in the abnormal. 
It does not denote any special form of disease, but merely an ex- 
cessive secretion of the mucous glands of the intestine as the result 
of some irritation. When it is thoroughly mixed with the feces 
it usually comes from the small intestine; when in combination 



94 STOOLS IN INFANCY 

with a clay-colored stool, from the duodenum; when on the out- 
side of a constipated stool, from the rectum. Stools composed 
mostly or entirely of mucus and blood indicate either severe in- 
flammation of the colon or intussusception. Undigested starch is 
often mistaken for mucus. It can be distinguished by the addi- 
tion of some preparation of iodine, which stains starch blue but 
does not affect the mucus. The suspected material should be 
taken off of the diaper in order to avoid possible confusion because 
of the presence of starch on the diaper. It is of importance not 
to use too strong a solution of iodine. 

Blood. — Blood on the outside of a constipated stool indicates 
a crack of the anus. Blood mixed with mucus indicates either 
severe inflammation of the large intestine or intussusception. 
Blood in infancy is seldom due to hemorrhoids. In rare instances 
the hemorrhage may come from an intestinal polyp. Hemorrhage 
from the bowel in the first few days of life is ordinarily a symptom 
of hemorrhagic disease of the new-born. 

Pus. — Pus indicates severe inflammation of the large intestine. 
It is usually not present early in the disease, but appears later. 
When the infants survive the acute stage it persists into convales- 
cence. Pus can be found with the microscope in nearly every case 
of inflammation of the colon, but is of no special significance un- 
less visible macroscopically . 

Membrane. — Membrane indicates very severe inflammation of 
the large intestine and is rarely seen, the patients usually dying 
before membrane appears in the stools. 

Other abnormal constituents are undigested masses of food, 
foreign bodies which have been swallowed, and worms. 

MICROSCOPIC EXAMINATION OF THE STOOLS 

The macroscopic examination of the stools affords data suffi- 
ciently reliable for clinical work in the great majority of instances. 
It may, however, lead to erroneous conclusions, especially with 
regard to the amount of fat and undigested starch. Fatty and 
starchy stools sometimes appear perfectly normal macroscopically, 
and microscopic examination will alone prevent mistakes. It is 
advisable, therefore, in all but the plainest cases, to examine the 
stools microscopically as well as macroscopically. The microscopic 
examination of the stools is not a difficult procedure, and can be 
carried out in ten minutes or less by anyone accustomed to it. 
Controls of the microscopic examination by chemical examination 
of the stools have shown that it gives results sufficiently reliable 






STOOLS IN INFANCY 95 

for clinical purposes. A certain amount of experience is necessary, 
however, in order to recognize the variations in the microscopic 
picture. The stools normally show a certain amount of fat in 
some form or other, but never show undigested starch. The chief 
difficulty in the microscopic examination is to learn to recognize 
the normal variations in the amount of fat. 

The feces, if hard, are first rubbed up with a little water. It is 
important not to dilute them too much. If not hard, they are 
thoroughly mixed. A small portion is then spread out very thin 
on a slide under a cover-glass and examined for the presence of un- 
digested tissues or pathological elements, such as blood, pus and 
eggs of parasites. 

The second portion is stained with LugoFs solution (iodine 2, 
potassium iodide 4, distilled water 100), or Gram's solution, 
(iodine 1, potassium iodide 2, distilled water 300), and examined 
for starch. The starch granules stain blue or violet. Certain 
microbes also stain blue. These, the so-called iodophilic bacteria, 
are associated with faulty carbohydrate digestion, and, when 
found alone without other symptoms, are suggestive of a begin- 
ning disturbance in the digestion of the carbohydrates. Before 
concluding that undigested starch is present, all possibility of 
contamination with baby powders must be eliminated. A diag- 
nosis of starch indigestion should never be made unless the char- 
acteristic form of the starch granules is made out. Negative 
microscopic findings, however, do not absolutely exclude the 
presence of starch from the stools. De Just and Constant 1 
showed that small amounts of starch could be detected even 
when it was not visible under the microscope. 

A third portion, undiluted with water, is stained with a saturated 
alcoholic solution of Sudan III. The neutral fat drops and fatty 
acid crystals stain red. Soap crystals do not stain with Sudan III. 
After this specimen is examined and the microscopic picture is 
clear, a drop of glacial acetic acid is allowed to run under the cover- 
glass, is thoroughly mixed in, and then heated until it begins to 
simmer. It should not be boiled, because, if it is, the fat is likely 
to be driven to the edge of the cover-glass and lost. This pro- 
cedure converts the soap into fatty acids which appear as large 
stained drops. They crystallize upon cooling. They usually re- 
tain the red stain. Any increase in the amount of fat after the 
addition of acetic acid indicates the presence of a corresponding 
amount of soaps. 

1 De Just and Constant: Bull. Sci. Pharmacolog., 1913, xx, 707; idem., 1914, 
xxi, 28. 



96 



STOOLS IN INFANCY 



This method of staining, while it enables us to distinguish be- 
tween the amount of neutral fat and fatty acids together, on the 
one hand, and of soaps, on the other hand, does not make it possi- 
ble to determine how much of the fat is in the form of neutral fat. 
This point can be determined by the use of carbol-fuchsin. The 
stain may be prepared as it is for staining tubercle bacilli. This 
may be too strong, however, and, if so, the solution should be 
diluted with an equal amount of 95% alcohol. Carbol-fuchsin 
does not stain neutral fat, but stains fatty acids a brilliant red 
and soaps a dull red. The following table shows the difference in 
the staining properties of neutral fat, fatty acids and soaps. 

TABLE 17 



Stain 


Neutral fat 


Fatty acids 


Soaps 


Sudan III 

Diluted carbol- 
fuchsin 


Drops staining 
orange red 

Drops do not 
stain 


Drops staining red, 
or crystals stain- 
ing orange-red 

Drops and crystals 
stain brilliant red 


Crystals do not 
stain 

Crystals stain dull 
red 



It is possible, therefore, by using these two stains in conjunction, 
to determine accurately enough for clinical purposes the relative 
proportions of neutral fat, fatty acids and soaps in the stool. An 
excess of neutral fat indicates that the digestion of fat is not carried 
on normally; an excess of fatty acids and soaps, that the digestion 
is normal but absorption is abnormal. It must be remembered in 
interpreting the importance of an excess of fat in the stool, that 
the younger the baby, the less is the significance of an excess of fat 
and vice versa. 

Laws and Bloor * have recently developed a method by which 
the amount of fat in a stool may be accurately determined in 
about one hour. This method, however, requires a well-equipped 
laboratory and considerable knowledge of chemistry. 

It is well to examine the specimen first with a low-power objec- 
tive and later with a high-power in order to bring out the detailed 
structure. 



THE BACTERIOLOGIC EXAMINATION OF THE STOOLS 

Our knowledge of the bacteriology of the disturbances of diges- 
tion and of the various inflammatory diseases of the intestine is so 

1 Laws and Bloor: Am. Jour. Dis. Ch., 1916, xi, 229. 



STOOLS IN INFANCY 97 

limited at present that no conclusion of clinical importance can be 
drawn from the microscopic examination of the stools, the only ex- 
ception being possibly the presence of large numbers of iodophilic 
bacteria, which, as already stated, point to disturbance of the 
digestion of the carbohydrates. In general, Gram-positive bacteria 
will predominate in an acid and Gram-negative in an alkaline 
stool. The determining factors are the same as those which cause 
the reaction of the stool. 

STOOLS OF DIFFERENT TYPES OF INDIGESTION 

The characteristics of the stools in some of the more marked 
types of indigestion are fairly definite. They are summarized be- 
low. 

The Stools of Fat Indigestion. — Undigested fat may show it- 
self in the stools in the form of small, soft curds, by giving a greasy, 
shiny appearance to the stool or by giving it a gray or white color. 
The small curds are, of course, easily recognized. Sometimes the 
stools have an oily appearance and the color is that of Indian meal. 
The presence of undigested fat may be shown roughly by rubbing 
some of the stool on a piece of smooth, soft paper. If there is an 
excess of fat, the paper will have, when dry, the appearance of 
oiled paper. When there is an excess of neutral fat, the stools are 
often of a creamy consistency. If the fat is largely in the form of 
soaps, the stools are usually clay-colored or very dry and crumbly. 
The reaction is highly acid. The odor is rancid, like that of 
butyric acid. Microscopically, these stools show a large excess of 
fat in various forms. 

The Stools of Carbohydrate Indigestion. — The character of the 
stools of carbohydrate indigestion depends on whether the dis- 
turbance is in the digestion of starch alone without bacterial 
action or in the digestion of either or both starch and sugar with 
bacterial fermentation. When the disturbance is solely in the 
digestion of starch and the bacterial fermentation is not marked, 
the stools are brown or golden-yellow in color and salve-like in 
consistency. They may, as already stated, appear macroscopically 
normal. In rare instances they are very dry and brittle. The 
reaction is acid. The odor is acid, the character of the odor depend- 
ing on the form of acid present. The iodine test will often show the 
presence of undigested starch macroscopically. Microscopically 
these stools show undigested starch by the iodine test, and an 
excess of iodophilic bacteria. 

When bacterial fermentation is added to the disturbance of 



98 STOOLS IN INFANCY 

digestion of either starch or sugar, the stools are loose, green and 
frothy. The reaction is acid from the presence of lactic, acetic or 
succinic acid. The odor is acid, the character of the odor depend- 
ing on the form of acid present. These stools often cause excoria- 
tion of the buttocks and genitals. 

The Stools of Protein Indigestion. — The presence of large, 
tough curds in the stools is, of course, evidence of protein or rather 
casein indigestion. In general, however, the stools of protein in- 
digestion are loose, brownish in color, alkaline in reaction and 
with a foul odor, the odor in some instances being fecal, in others 
cheesy, in others a combination of the two. 

Mixed Forms of Indigestion. — Mixed types of stools as the 
result of mixed types of indigestion modified by bacterial fermenta- 
tion and decomposition are far more common than the pure types 
alone and are often very difficult to interpret. 

The examination of the stools gives information regarding the 
digestive processes which cannot be obtained in any other way. 
Without such examination the treatment of disturbances of diges- 
tion is always unscientific and often irrational. The macroscopic 
examination of the stools affords information of the greatest im- 
portance, but in many instances will lead to error unless the 
microscopic examination is also made. The microscopic examina- 
tion is a simple one and requires but little time. The results ob- 
tained from it are, for practical purposes, as reliable as those ob- 
tained from the chemical examination. The stools should be 
examined both macroscopically and microscopically in every dis- 
turbance of the digestion in infancy. 



SECTION II 
BREAST FEEDING 

CHAPTER IX 
GENERAL CONSIDERATIONS 

It is generally recognized that the natural food for the human 
infant is human milk, that breast-fed babies are more likely to live 
than the artificially-fed and that, as a class, they are healthier, 
more vigorous and more resistant. Few appreciate, however, how 
much greater the mortality is in the artificially-fed than in the 
breast-fed. There are many statistics to prove this fact. It is 
hardly necessary, however, to give more than a few of them. 

Mortality. — In Berlin, where the character of the feeding of 
all living children is determined by the census, during the five 
years, 1900 to 1904, only 9% of the infantile deaths were in breast- 
fed babies. 1 The Department of Health of New York City esti- 
mates that over 85% of all infantile deaths are in those artificially 
fed. 2 Davis 3 found that in Boston, in 1911, 74% of the deaths of 
infants over two weeks of age were in the artificially-fed, and 
calculates that in Boston the bottle-fed is six times as likely to die 
as the breast-fed infant. Luling,* in a study of 13,952 children 
born in Baudeloque's clinic, found an infant mortality of 14% in 
the breast-fed, 31% in those who were bottle-fed by their own 
mothers, and 50% in those who were bottle-fed by strangers. 
Armstrong, 5 in a study of 1,000 infants in Liverpool, in 1903, 
found that 8.4% of the breast-fed babies died in the first year 
against 22.8% of the artificially-fed. Of 1,000 fatal cases of 
diarrheal disease investigated by the Health Department of the 
City of New York, in 1908, only 90 had previously been entirely 
breast-fed. 2 Further evidence of the effect of breast feeding on the 
infant mortality is the fact that during the Siege of Paris, 1870-71, 

1 Graham: Journal A. M. A., 1908, li, 1045. 

2 Holt: Journal A. M. A., 1910, liv, 682. 

3 Davis: Amer. Jour. Diseases of Children, 1913, v, 234. 
4 Luling: These de Paris, 1900. 

6 Armstrong: British Jour. Children's Diseases, 1904, i, 115. 

99 



100 BREAST FEEDING 

while the general mortality rate doubled, the infant mortality rate 
fell from 330 to 170 per thousand deaths, the reason being that the 
women, having no other food to give their babies, had to nurse 
them. 1 

Relative Frequency of Breast Feeding. — The relative fre- 
quency of breast feeding varies in diffierent countries and in differ- 
ent races. In Japan, breast feeding is the rule. In Greenland, and 
among the Eskimos, artificial feeding is practically unknown. The 
proportion of breast-fed babies is much smaller in other countries. 
Nordheim, 2 for example, found, as the other extreme, that only 
3.6% of 1,000 women coming to the Women's Dispensary in 
Munich, nursed their babies longer than three months. Davis, 3 
from an investigation made in 1911, estimated that 68% of all 
Boston babies between the ages of two weeks and one year were 
breast-fed, while the Board of Health of the City of New York 
estimates that about 85% of the infants in New York are breast- 
fed. 4 Holt, 4 however, thinks that, as these data were gathered 
largely from the tenement district statistics, they are too high, 
and that 80% is nearer the truth for the entire population. Kop- 
lik 5 found that 10% of 1,007 infants, seen in private practice 
in New York City, were exclusively breast-fed, 30% exclusively 
bottle-fed and 60% breast and bottle-fed. Forty per cent of these 
were weaned before the fourth month. 

Ability of Women to Nurse Their Babies. — There are two rea- 
sons why women do not nurse their babies. They are either unable 
or unwilling. There is much difference of opinion as to what 
proportion of women are really able to nurse their babies, although 
it is generally conceded that a large proportion of those who do not 
nurse their babies could nurse them, if they thought they could or 
were compelled to do so. Nordheim 2 found that of 1,000 women 
642 had never nursed, and that 86.7% of these had no good reason 
for not nursing. Dluski 6 found that 99% of the women in the 
Maternity Department of Professor Pinard, in Paris, were able to 
nurse their babies. Holt 4 estimates, however, that not over 25% 
of the well-to-do and cultured women of New York City are able 
to nurse their babies over three months. 

There is no doubt that a far larger proportion of women can 

1 Brehmer: Wochenschr. f. Sauglingsfursorge., 1907, 209. 

2 Nordheim: Archiv. f. Kinderheilk., 1901, xxxi, 89. 

3 Davis: Amer. Jour. Diseases of Children, 1913, v, 234. 
^ Holt: Journal A. M. A., 1908, li, 1045. 

6 Koplik: Journal A. M. A., 1912, lviii, 75. 
6 Dluski: These de Paris, 1894. 



BREAST FEEDING 101 

nurse their babies than was formerly supposed. Martin 1 found 
that in Wiirtemberg, where formerly only 41% of the women in the 
clinics nursed their babies, 100% are now capable. Constant 
instruction at the Consultations des Nourrissons, in France, has 
increased the number of cases of maternal feeding among the 
poor by 20% or 30%. The experience at similar institutions in this 
country has been the same. There is a general belief, moreover, 
although there are no figures to prove it, that the ability of women 
in the wealthier and more highly educated classes in this country 
to nurse is steadily increasing. 

Unwillingness to Nurse. — The main reason why women do not 
nurse their babies is that they do not appreciate its importance. 
This is due to a considerable extent to the fact that they do not 
receive proper advice from doctors, nurses and midwives, who, 
unfortunately, are themselves in many instances ignorant of the 
importance of breast feeding. The unwillingness to nurse among 
the wealthier and fashionable classes is in part because they are 
unwilling to sacrifice their own pleasure and convenience, in part 
because it is not fashionable in certain circles to nurse, and in part 
because of the opposition of their husbands, who do not wish to be 
deprived of their wives' society. Many of them feel, moreover, 
that on account of the great improvement in artificial feeding, 
their babies will do well enough, even if they do not nurse them. 
The unwillingness of women among the poorer classes to nurse 
their babies is, in many instances, due to the fact that on account 
of poverty they are obliged to go to work. Ignorance of the ad- 
vantage of breast feeding plays a greater part in their unwilling- 
ness to nurse than among the better educated, as do also the 
advertisements of proprietary foods. 

Contraindications to Breast Feeding. — A woman with active 
pulmonary tuberculosis should not nurse her baby, because of the 
great danger of infection of the baby. It is usually inadvisable 
for a woman with healed tuberculosis, pulmonary or otherwise, or 
with closed tuberculosis, to nurse her baby, because of the danger of 
starting up or increasing the activity of the process. Although 
tubercle bacilli are sometimes present in the milk of tuberculous 
women, the danger of infection from this cause is negligible. 
Syphilis is not a contraindication to nursing because, if the mother 
has active syphilis the baby has been infected before birth, and if 
the baby has syphilis, the mother always has it. Insanity is a 
contraindication to nursing as is, in most instances, epilepsy. Very 
delicate or feeble women and women suffering from serious chronic 
1 Martin: Archiv. f. Gyn., 1905, lxxiv, 513. 



102 BREAST FEEDING 

diseases should not nurse their babies, partly because their milk is 
usually of poor quality, and partly because the strain of nursing 
is certain to do them serious harm. It is usually inadvisable for 
women that have had severe hemorrhages, who are septic or who 
have nephritis to nurse their babies. Women suffering from puer- 
peral eclampsia should not nurse their babies, because of the danger 
of the production of serious or even fatal symptoms in the babies, 
which are probably manifestations of anaphylaxis. Women who 
have been unable to nurse previous children satisfactorily can 
hardly be expected to nurse. It is wiser, however, for them to 
make the attempt because they are sometimes able to do it, al- 
though unsuccessful in the past. 

A certain number of infants are unable to nurse because of 
deformities of the lips and mouth. Premature infants are often too 
weak to nurse, as are some congenitally feeble babies. Such babies 
should not, however, be deprived of the advantages of human milk. 
The milk should be pressed from the breast, or drawn with a 
breast pump and fed to the baby with a dropper, spoon or Breck 
feeder, or through a tube. 



CHAPTER X 
HUMAN MILK. CHEMISTRY AND BIOLOGY 

The Breast Glands. — Glands which secrete milk are present, as 
a rule, in the female mammal only during and after pregnancy. 
A few drops of milk may be squeezed from the breasts before 
parturition, but, generally speaking, milk is present in them only 
after delivery. 

According to Czerny and Keller 1 if the infant does not empty 
the breasts and they fill up again with secretion, there is a change 
in the composition of the milk as the result of the absorption of its 
different components. It is, therefore, necessary to differentiate 
between the milk of women whose breasts are regulated and 
sufficiently emptied during nursing and those of women whose 
breasts are not sufficiently emptied. In the first there is no absorp- 
tion of the milk components in the glands, while in the latter the 
chemical composition is more or less changed by absorption. They 
designate the latter as colostrum. Under this term they include 
all milk in which there has been any absorption; not only the milk 
in the breasts during pregnancy and the first few days postpartum, 
but also the milk when the secretion is in the process of drying up. 
It may also be found in the breasts of non-pregnant women, even 
after they have reached the menopause. 2 

Colostrum. — All authors agree that the milk excreted during the 
first few days postpartum differs essentially from that after lacta- 
tion is well established. It is of a deep lemon-yellow color. This 
color is present only during the first few days postpartum and is 
never seen at any later stage of lactation. Czerny (p. 408) be- 
lieves, on the basis of his own work, that this color is due to a 
coloring matter contained in the fat drops. The colostrum is not 
as sweet as the later milk. It is coagulated into solid masses by 
heat. This depends, according to Tiemann, 3 on the presence of a 
globulin, which coagulates at 72 C. (161.6 F.). The amount of 

1 Czerny and Keller: Des Kindes Ernahrung, Ernahrungsstorungen, und 
Ernahrungstherapie, Leipzig and Wien, 1906, i, 407. 

2 Gardlund: Hygiea, Stockholm, 1917, lxxix, No. 3, 97; Abstr. Jour. A. M. A., 
1917, lxviii, No. 16. 

3 Tiemann: Ztschr. f. Physiol. Chem., 1898, xxv, 363. 

103 



104 HUMAN MILK, CHEMISTRY AND BIOLOGY 

cholesterin and lecithin is greater than in milk. 1 The fat in colo- 
strum contains less of the volatile fatty acids than does normal 
milk. 2 

It is obvious that only those analyses of colostrum which have 
been made during the first days postpartum are of any value, as 
later it is mixed with milk. The specific gravity of colostrum 
ranges from 1.028 to 1.072, the average being about 1.040. 3 It has 
a strongly alkaline reaction. 

J. Konig 4 gives the following percentages as the average of five 
analyses of early human colostrum; Water, 86.4; nitrogenous sub- 
stances, 3.07; fat, 3.34; lactose, 5.27; salts, 0.40. 



TABLE 18 

Composition op Colostrum as Determined by Various Investigators 
(czerny and keller) 



Author 


Day, post- 
partum 


Fat 

per cent. 


Lactose, 
per cent. 


Protein, 
per cent. 


Nitrogen, 
per cent. 


Ash, 
per cent. 


Solids, 
per cent. 


Pf eiffer 5 


1 
2 


2.59 
2.17 
3.77 
4.08 
3.92 
1.67 
2.02 


2.76 
3.50 
5.39 
4.09 
5.48 
5.20 
5.08 


9.75 
7.45 
3.31 


0.928 
0.508 
0.336 
0.226 


0.408 

0.340 

0.27 

0.48 

0.41 

0.36 

0.40 




Pf eiff er 




V. & J. Adriance 5 
Camerer and Sold- 
ner 7 




2 

' 26-51 * 

56-61 *f 

26-48* 

48-69 * t 


12.78 
16.04 
14.12 




10.32 
10.12 



* Hours. 



f Same woman. 



Pfeiffer, 8 found that the nitrogenous substances in human milk 
were as follows: First day, 8.6%; third to seventh day, 3.4%; 
during second week, 2.28%; in second month, 1.84%; in seventh 
month, 1.52%. The amount of sugar increases as the protein in 
human milk diminishes. The mineral composition of colostrum 
and breast milk is materially different. Table 19 shows the com- 
position of one hundred grams of colostrum as compared with one 
hundred grams of milk. 9 

The findings of Burr, Bermerich and Berg 7 were somewhat 

1 Voltz: Oppenheimer's Handbuch der Biochemie, Jena, 1910, iii, I, 382. 

2 Nilson: Maly's Jahresb., 1891, xxi, 142. 

3 Burr, Bermerich and Berg: Chem. Ztg., xxxvii, 69-71, 97-101. 

4 Konig, J. : Die Menschl. Nahrungs u. Genussmittel, Berlin, 1904, ii, 598. 
^ Pfeiffer: Jahrb. f. Kinderh., 1883, xx, 365. 

6 Adriance, V. and J. : Archives of Pediatrics, 1897, xiv, 22. 

7 Camerer and Soldner: Ztschr. f. Biol., 1898, xxxvi, 277. 
8 Birk: Monatschr. f. Kinderh., 1910-1911, ix, 595. 

9 Berg: Chem. Ztg., xxxvii, 146. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 105 

different. They found that colostrum contained twice the amount 
of phosphorus, magnesium and calcium normally present in milk 
after lacation is well established. 

Colostrum Corpuscles. — Microscopically the fat droplets in 
colostrum are more unequal in size than in ordinary milk. The 

TABLE 19 
Composition op 100 Gm. Colostrum as Compared with Milk (Birk) * 



Colostrum (Birk) 


Human milk 


Ash 

Calcium 


0.2814 

0.0360 

0.0093 

0.077 

0.0544 

0.1137 


0.0198 

0.2 -0.25 . 
0.0328-0.0343. 
0.0378 


Langstein and Meyer 

Abu-Neuberg 

Bunge 

Camerer and Soldner 


Magnesium. . . . 


0.0064-O.0065. 
0.0053 


Bunge 

Camerer and Soldner 


Potassium 


0.078 -0.0703. 
088 


Camerer and Soldner 

Camerer and Soldner 


Sodium 


0.0357 


Camerer and Soldner 


Phosphorus. . . . 


0.0473-0.0469. 
0.0591 


Bunge 

Carnerer and Soldner 







colostrum also contains large numbers of granular bodies, known as 
" colostrum corpuscles." They are four or five times as large as the 
leukocytes, are nucleated and are full of fat droplets. They are 
characteristic components of milk at the beginning of lactation, 
and are not found in later lactation. They have ameboid motion. 1 
Czerny identified them as large leukocytes, whose cell membranes 
are completely filled with fat drops. These fat drops are smaller 
than those in the milk. He was able to demonstrate that the leu- 
kocytes of frogs possess the power of emulsifying fat drops and 
explains their small size in this way. He further emphasized the 
fact that it had previously been thought that these bodies were 
only present in the milk during the first days of lactation. Buch- 
holz 2 noticed in 1877, however, that the colostrum bodies reap- 
peared in the milk when nursing was stopped and the milk was 
drying up. Czerny repeated his work and found that the colostrum 
bodies always reappeared in the milk when lactation was inter- 
rupted for a few days, and that their numbers increased in direct 
proportion to the length of time which had elasped since the breasts 
were emptied. He concluded that colostrum corpuscles were al- 
ways present when milk was formed in the breasts but was not 
withdrawn and that they disappeared when the breasts were suffi- 



1 Czerny and Keller, page 409. 



2 Czerny and Keller, page 410. 



106 HUMAN MILK, CHEMISTRY AND BIOLOGY 

ciently emptied of milk. Animal experiments show that the colo- 
strum bodies pass from the breasts into the lymphatics. These 
colostrum corpuscles contain neutrophilic granules. 1 According to 
Deville, 2 they disappear from the milk between the eighth and 
tenth day in 51% of the cases. They may, however, in rare in- 
stances persist for many weeks. 3 

They are also phagocytic, in that they will consume bacteria. 
They have been shown to consume staphylococci, the colon bacil- 
lus, and the tubercle bacillus. 4 

When the breasts are not completely emptied, the protein and 
sugar are reabsorbed into the body earlier than the fat, which is 
taken up by the colostrum corpuscles only after five or six days. 
The sugar may appear early in the urine. The albumins in milk 
have a different hemolytic action from those in the blood of the 
same species, while those in colostrum react the same. On the 
basis of these facts, Bauer 5 argues that the proteins in colostrum 
are a direct transudate from the blood, while those in milk are 
manufactured by the mammary gland. 

The protein of colostrum is characteristic since the greatest part 
of it will coagulate. Acid coagulation occurs very easily and the 
curd is tough. 

The colostral fat is richer in oleic acid than is milk fat and as a 
result the iodin index is considerably higher. 6 

HUMAN MILK 

Bacteriology. — Since the infant takes the milk directly into 
the mouth from the breasts, only such organisms as are in the 
breast gland itself can get into the milk. 7 

1 Cohn: Virchow's Arch. f. path. Anat., 1900, chdi, 187. 

2 Deville: Arch, internat. de med. leg., 1913, iv, 60. 

3 Steele: Arch. Pediat., 1910, xxvii, 32. 

4 Thomas: Vortr. geh. a. d. Vereinig, Sachs-Thuring; Kinderarzte in Dres- 
den, 1913, Ref.; Ztschr. f. Kinderh. (Ref.), 1913, vi, 28. 

5 Bauer: Deutsch, med. Wochenschr., 1909, xxxv, 1657. 

6 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

7 Escherich: Fortschr. d. Med., 1885, iii, 231; Cohn and Newmann: Vir- 
chow's Arch. f. path. Anat., 1891, cxxvi, 391; Palleske: Virchow's Arch., 1892, 
cxxx, 185; Honigmann: Ztschr. f. Hyg. u. Infectionskr., 1893, sdv, 207; Ringel: 
Munchen. med. Wochenschr., 1893, xl, 513; Genoud: Sur la presence du staphy- 
locoque dans la lait des accouchees bien portantes, These de Lyon, 1894; 
Knochenstiern: Hyg. Rundschau, 1894, iv, 231; Halleur: Inaug. Diss. Leipzig, 
1893; Brumm: Arch. f. Gynaecol., 1886, xxvii, 461; Merit: These de Paris, 
1887; Johanessen: Jahrb. f. Kinderh., 1895, xxxix, 398; Roeper: Inaug. Diss., 
Marburg, 1896; Koestlin: Arch. f. Gynaecol., 1897, liii, 201. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 107 

These investigations show that the milk of healthy women, 
whose breasts are free from pathologic conditions, contains micro- 
organisms in the majority of instances. In the majority of cases 
the organism is staphylococcus aureus. Most investigators be- 
lieve that the bacteria get in from the outside. Evidence in favor 
of this view is the fact that it is easier to demonstrate these or- 
ganisms in the first part of the milk drawn than in the last part. 
Finally when the milk is withdrawn gently drop by drop, rather 
than strongly and rapidly, many tests are sterile. This fact makes 
it seem probable that the rough handling of the breast gland during 
nursing or by massage dislodges the bacteria and forces them into 
the milk. 

Syphilitic lesions have been induced in rabbits by inoculating 
them with milk from syphilitic women, although the milk was 
sterile and no spirochaeta pallida were 'found in the milk. 1 

Typhoid bacilli have been found by Lawrence 2 in the milk of 
a woman suffering with typhoid fever. 

Under normal conditions no ill effects are caused by the bac- 
teria in human milk. The children who take this milk thrive in 
spite of the presence of bacteria in the first portion of the milk. 
The bacteria in human milk have no pathologic significance for 
the healthy infant. It has been shown that this is not the fact in 
babies with disturbances of digestion. Moro 3 has recently as- 
cribed to the staphylococci in human milk an etiologic role in the 
dyspeptic conditions of breast-fed infants. 

Appearance, Smell and Taste. — Human milk has the same 
appearance as cow's milk, except that, when it is cooled, small 
white flakes are apt to stick to the side of the bottle. These flakes 
disappear when the milk is warmed. It has no odor and its taste 
is sweet. The color, however, varies in different milks from a 
rich yellow, creamy appearance to a bluish white. The former is 
supposed to contain more fat than the latter; this, however, is 
not always the case as is shown by two milks examined by Dr. 
Dennis at the Mass. Gen. Hospital (not yet reported), whose 
color was a rich yellow and contained less than 1% of fat. If the 
nursing mother eats liver, a green coloration often appears in the 
milk about sixteen hours after the meal. This color is probably 
due to bile salts. 4 

Microscopic Appearance. — It contains many minute fat drop- 

1 Uhlenhuth and Mulzer: Deutsch. med. Wochenschr., 1913, xxxix, No. 19. 

8 Lawrence: Boston Med. and Surg. Jour., 1909, cbri, 152. 

8 Moro: Jahrb. f. Kinderh., lii, 542. 

* Feer: Zurich Biochem. Zeitschr., 1916, lxxii, 378. 



10S HUMAN MILK, CHEMISTRY ANN BIOLOGY 

lets which are held in a state of permanent emulsion by the solu- 
tion in which they are suspended. It may contain a few leuko- 
cytes and epithelial cells. The ultramicroscope shows numerous 
fine particles in lively molecular motion between the fat droplets. 
These particles are less numerous than in cow's milk. They are 
composed of casein. 1 

Specific Gravity. — The specific gravity averages between 1.030 
and 1.032. It may fall as low as 1.020 and rise as high as 1.036. 2 
Reaction. — The reaction of human milk is amphoteric. It is 
acid to phenolphthalein and alkaline to litmus. The reason for 
the double reaction is the fact that the milk contains both mono- 
and diphosphates. The former are weakly acid, while the latter 
react as a base. If 10 c. c. of human milk are titrated with deci- 
normal acid and litmus, it will require about 0.9 to 1.25 N/10 acid 
to neutralize them; it requires 0.12 to 0.55 N/10 NaOH with 
phenolphthalein. One hundred cubic centimeters of milk require 
60 to 80 c. c. N/10 HC1 to show the Gunzburg reaction. 3 The 
alkaline reaction of human milk is relatively stronger than the acid 
reaction, but the absolute amount of acidity and alkalinity are less 
than in cow's milk. The electrical measurement of human milk as 
well as of all other milks is neutral. 4 The average hydrogen ion 
concentration is, according to Clark, 5 between 1.07 and .60 X 10~ 7 . 
Quantity. — The amount of human milk secreted by healthy 
mothers depends on the demands of the infant. The twenty-four- 
hour amount of milk, therefore, depends in large part on the 
weight and strength of the infant. It is obvious that what might 
be a normal amount for one infant would be abnormal for another, 
and for this reason averages are of no greater value than the aver- 
age weight of the infant. The figures representing the amount of 
milk taken by the infant are obtained by weighing either the 
mother or the baby before and after each nursing. The table of 
Cramer's 6 figures shows the difference between the secretion of 
milk in primiparae and multipara : 

1 Alexander and Bullowa: Jour. Am. Med. Assn., 1910, lv, 1196; Mauntner: 
Arch. f. Kinderh., 1908-9, xlix, 29; JKreidl and Neumann: Pfiuger's Arch., 
1908, cxxiii, 523. 

2 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 774; Konig: Note 9. 

1 Courant: Pfluger's Arch., 1891, i, 109; Escherich: Verhandl. d. Versamml. 
d. Ges. f. Kinderh., Heidelberg, 1889, 109. 

2 Foa: Soc. Biol., 1905, lviii, 863; 1905, lix, 51. 

3 Clark: Jour. Med. Research, N. S., 1915, xxvi, 431. 

4 Cramer: Klin. Beitr. z. Frage der kunstlichen Ernahrung des Neuge- 
borenen. Inaug. Diss., Breslau, 1896. Taken from Czerny and Keller, Des 
Kindes, etc., Vol. 1, p. 356. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 109 



TABLE 20 
Twenty-Four Hour Amount of Milk in Grams 



Day postpartum 



1 


2 


3 


4 


5 


6 


7 


8 


9 


4 


78 


183 


199 


236 


299 


303 


274 


362 


6 


129 


238 


324 


344 


324 


361 


365 


384 



10 



Nine babies of primiparae; 
average birth weight, 
3,290 gm 

Seven babies of multi- 
para; average birth 
weight, 3,348 gm 



384 



415 



Table 21 from Czerny and Keller x gives the figures that Feer 
calculated as the amount of milk babies of the average weight 
(Camerer's figures) would take in a day. They do not differ 
much from those given by Camerer. 

Czerny and Keller * (Vol. I, Chapter 18) should be consulted 
for a more detailed discussion of the amounts of breast milk se- 
creted by the average woman. These amounts may be increased 
when a woman nurses two or more babies as does the wet-nurse. 
A wet-nurse 2 increased the amount of milk secreted in ten days 
from 720 grams when she nursed two infants to 1,750 grams when 
she nursed five infants. 

TABLE 21 
Average Daily Amount op Milk Drawn by a Baby (From Czerny and 

Keller) 





Average 






Average 




Age in 


weight of 
breast-fed 
babies ac- 


The calcu- 
lated day's 


Age in 


weight of 
breast-fed 
babies ac- 


The calcu- 
lated day's 


weeks 


cording to 


amount of 


weeks 


cording to 


amount of 




Camerer, 


milk, gm. 




Camerer, 


milk, gm. 




gm. 






gm. 




1 


3,410 


291 


14 


5,745 


870 


2 


3,550 


549 


15 


5,950 


878 


3 


3,690 


590 


16 


6,150 


893 


4 


3,980 


652 


17 


6,350 


902 


5 


4,115 


687 


18 


6,405 


911 


6 


4,260 


736 


19 


6,570 


928 


7 


4,495 


785 


20 


6,740 


947 


8 


4,685 


804 


21 


6,885 


956 


9 


4,915 


815 


22 


7,000 


958 


10 


5,055 


800 


23 


7,150 


970 


11 


5,285 


808 


24 


7,285 


980 


12 


5,455 


828 


25 


7,405 


990 


13 


5,615 


852 


26 


7,500 


1,000 



1 Czerny and Keller: i, 353. 



2 Czerny and Keller: 358. 



110 HUMAN MILK CHEMISTRY AND BIOLOGY 

Coagulation. — The recent observations with the ultramicro- 
scope ! have helped to explain the coagulation of milk. The essen- 
tial differences in the coagulation of human and cow's milk are 
as follows: The casein of human milk is precipitated with greater 
difficulty with acids or salts and it does not coagulate uniformly 
after the addition of rennet; and, lastly, the clot that forms does 
not appear in such large coarse masses as the casein from cow's 
milk, but is more loose and flocculent. 

(a) Precipitation with Acids. — Bienenfeld 2 showed that there 
is a certain acidity at which the casein is precipitated most easily. 
When lactic acid is used, this point is between 22 and 24 c. c. N/10 
acid to 100 c. c. of milk. If the milk is made acid up to this point 
and warmed to 40 C. (104 F.) the casein precipitates out of the 
solution. If the milk is diluted five times, the precipitation is 
accelerated. A watery, clear whey is left behind. Engel 3 showed 
that this was also true of strong acids (20 to 30 c. c. N/10 acid to 
100 c. c. milk), but the best results were only seen at a certain de- 
gree of acidity. Slight variations above or below this point did 
not give good results. When acetic acid is used, more is neces- 
sary, i. e., 60 to 160 c. c. N/10 of the acid to 100 c. c. milk. 

(b) Rennin Coagulation. — If a neutral solution of rennet is 
added to milk there is no macroscopic or microscopic change un- 
til the milk is acidified, but the ultramicroscope shows that the 
rennin ferment acts also in neutral solutions. 4 Although human 
milk does not coagulate uniformly with rennin, it has been shown 
that it is capable of coagulation. 5 After human milk has been 
frozen several days and then rennin plus acid are added, there is a 
definite coagulation. Human milk does not coagulate with rennin 
alone. Two factors may explain the diminished coagulability of 
human milk, viz., the relative alkalinity of the milk and its low 
calcium content. 6 Engel 7 saw a better precipitation when he 
diluted the milk with water that contained calcium, than when he 
used distilled water. The coagulation is also facilitated, if the 
milk is kept cold for several hours. 8 

The precipitate is characteristic and is always in more or less 
fine curds, which are never as large as the curd from acidified cow's 

1 Czerny and Keller: i, 458. 

2 Bienenfeld: Biochem. Ztschr., 1907, vii, 262. 

3 Engel: loc. cit., Note 19, p. 775. 

4 Kreidl and Neumann: (See note 4, 97). 

6 Schlossmann and St. Engel: Oppenheimer's Handbuch, etc., iii, 430. 

6 Fuld and Wohlgemuth: Biochem. Ztschr., 1907, v. 119. 

7 Engel: Biochem. Ztschr., 1908, xiii, 89. 

8 L. F. Meyers: Verhandl. d. ges. f. Kinderh., Stuttgart, 1906, p. 122. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 111 

milk. The curds in undiluted milk are especially fine and can be 
seen only with the microscope. It is interesting that they do not 
sink to the bottom in milk from which the cream has not been 
removed, but rise to the top. In skimmed milk they may fall to 
the bottom. 

(c) The Difference between Acid and Rennin Coagulation. — 
There is no macroscopic difference. The ultramicroscope shows 
that neutral solutions of rennin cause the casein, which was pre- 
viously invisible, to become visible. 3 Acid must subsequently 
be added to cause a definite precipitation. The curds from acid 
plus rennin coagulation are not so easily dissolved as those from 
acid coagulation alone. Chemically there results from rennin 
coagulation a casein body, which is rich in calcium — paracasein. 
The whey which results from rennin and acid coagulation, con- 
tains less nitrogen than that from acid precipitation. 1 

Chemical Composition. — The principal components of milk are 
fat, lactose, proteins, salts and water. It also contains small 
amounts of extractives and citric acid as well as certain unknown 
substances. 

Nitrogenous Bodies. — 1. Total Nitrogen. The total nitrogen 
in milk is usually determined by the Kjeldahl method and this 
figure is multiplied by the factor 6.25, or 6.37, to give the protein 
content. This method is, however, not free from error, because 
there are other bodies that contain nitrogen and yet are not classed 
among the proteins. These, according to various authors, 2 may 
make up between 17 and 20% of the total nitrogen. Taking this 
fact into consideration and deducting the non-protein nitrogen 
from the total nitrogen, there is, according to Camerer and Soldner, 
1.04% of protein in human milk. The average figures as to the 
total amount of nitrogen in 100 c. c. of milk at different stages of 
lactation are 3 as shown in the following table: 

1 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

2 Camerer and Soldner: Ztschr. f. Biol, N. F., 1898, xviii, 277; Rietschl: 
Jahrb. f. Kinderh., lxiv, 125. 

3 Schlossmann: Arch. f. Kinderh., 1900, xxx, 324; 1902, xxxiii, 187. 



112 HUMAN MILK, CHEMISTRY AND BIOLOGY 



TABLE 22 

Total Nitrogen in 100 C. C. Milk at Different Stages in Lactation 

(Schlossmann) 



Days postpartum 


Total nitrogen 


Nitrogen factor X6.25 


9 to 10 


0.29 


1.81 


11 to 20 


0.29 


1.81 


21 to 30 


0.31 


1.94 


31 to 40 


0.24 


1.50 


41 to 50 


0.28 


1.75 


51 to 60 


0.25 


1.56 


61 to 70 


0.23 


1.44 


71 to 100 


0.20 


1.25 


101 to 140 


0.20 


1.25 


141 to 200 


0.207 


1.29 


over 203 


0.21 


1.31 



The amount of protein varies in the milk of different women. 
Hammett, 1 found that on the third day it was 3.52%, and dropped 
rapidly so that on the eleventh day it was 1.46%. This latter 
figure is considerably lower than that given by Schlossmann for the 
same period. 

The amount of protein in the milk varies during the same day 
and even during a single nursing. These variations are, however, 
not of any great significance. The next table shows the variations 
in the milk of eight wet-nurses during a single day, samples having 
been taken from each of the nursings. The individual variations 
are so slight, however, that if the average for the day is taken 
and compared with the average for the stage of lactation, the same 
diminution in the amount of protein during the progress of lacta- 
tion is seen as in the table. 2 (The factor of nitrogen times 6.25 
was used.) 



1 Hammett: Jour. Biol. Chem., 1917, xxix, 381. 
2 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 
p. 810. 



1909, 



HUMAN MILK, CHEMISTRY AND BIOLOGY 113 



TABLE 23 

Variation of the Per Cent, of Protein in the Milk of Eight Wet- 
Nurses During a Single Day (Engel) 



Age 


Day 


















of 


of 






Morn- 






After- 






nurse, 


lacta- 


Am't, 




ing 






noon 




Avg. 


years 


tion 


c. c. 


5 


9 


12 


3 


6 


10 




16 


45 


2,000 


1.386 


1.458 


1.305 


1.324 


1.306 


1.279 


1.344 


19 


58 


1,500 


1.163 


1.118 


0.956 


1.073 


1.163 


1.127 


1.100 


29 


60 


2,200 


1.149 


1.154 


1.395 


1.261 


1.136 


1.161 


1.208 


25 


70 


2,700 


1.314 


1.243 


1.127 


1.216 


1.046 


1.064 


1.170 


23 


72 


3,000 


1.207 


1.234 


1.154 


1.315 


1.154 


1.163 


1.204 


21 


100 


3,300 


1.135 


1.117 


1.127 


1.154 


1.243 


1.028 


1.119 


19 


130 


1,800 


0.492 


1.019 


1.127 


1.064 


0.903 


1.082 


0.948 


25 


140 


2,200 


1.082 


1.064 


1.100 


0.939 


1.082 


1.064 


1.036 


















Avg. 1.141 



2. Residual Nitrogen. — The residual nitrogen is that fraction 
of the nitrogen which is found in the filtrate after the precipita- 
tion of the albumins and which does not give the reactions for 
protein. 2 Part of this residual nitrogen is supposed to be in the 
form of urea (50% or more) and another part in an amino-acid or 
a peptid-like body. 2 There is less of it in cow's milk than in hu- 
man milk. The significance of these bodies is unknown. 

The milk and blood serum of a 21-year-old primipara with 
chronic nephritis (urinary albumin = 0.3%) were simultaneously 
examined on two occasions. The residual nitrogen of the serum 
was 5.33% and 7.43% of the total nitrogen; that of the milk was 
27.19% and 32.88%, both being much above the normal. Urea 
was considered to be the probable cause of this increased amount. 3 

3. The Albuminous Bodies. — Human milk contains two groups 
of albuminous bodies: (1) casein, which is insoluble in water, and 
(2) lactalbumin and globulin, which are soluble in water. The 
separation of these bodies in human milk is more difficult than in 
cow's milk, because of the difficulty in precipitating the casein. 
There is, on this account, much opportunity for future investiga- 
tions to add to our knowledge of the proteins of human milk. The 
figures which are most generally adopted are those of Schloss- 



1 Munk: Virchow's Arch. f. path. Anat., 1893, 134, 501. (First studied 
this body.) 

2 Rietschel: Jahrb. f. Kinderh., Ixiv, 125. 

8 St. Engel and Murschauser: Ztschr. f. physiol. Chem., 1911, lxxiii, 101. 



114 HUMAN MILK, CHEMISTRY AND BIOLOGY 

maim, 1 who found that about 41% of the total nitrogen is in the 
form of casein. From 15 to 20% of the total nitrogen may, how- 
ever, be residual nitrogen (see above). If this amount is deducted 
only 44 to 39% are left to be divided between the lactalbumin and 
globulin. Ciccarelli 2 found that the relation of casein to lactal- 
bumin in human milk was 26.9-37.9 to 62.1-73.1. These figures 
show that there is considerable variation in the quantities of these 
bodies even in human milk. The following figures represent what 
may be considered averages. The total protein is divided as fol- 
lows: 

Casein, 41%; lactalbumin and globulin, 44 to 39%; residual 
nitrogen, 15 to 20%. 

Opalisin was described in 1888 by Wroblewski 3 as a new al- 
bumin which is present in very small amounts in cow's milk and 
in large amount in mare's milk. It is also present in human milk. 
Very little is known about this body. 



COMPARISON OF PROTEINS OF HUMAN AND COWS MILK 

Casein. — The facts that it is difficult to precipitate casein from 
human milk and that it takes large amounts of milk to obtain a 
sufficient quantity of casein for analysis have retarded our knowl- 
edge of the subject. For this reason more is known about cow 
casein than human casein. 

Casein is insoluble in water, but is soluble in water to which 
alkalies have been added. If acid is added to this alkaline solu- 
tion, the casein will again be precipitated. If enough alkali is 
subsequently added it will again go into solution. The analysis 
of casein is shown in Table 24. 

TABLE 24 
Analysis of Casein (From Engel) 



Author 


C 


H 


S 


P 


N 


Wroblewski 4 


52.24 
53.01 
52.63 


7.32 
7.14 
6.94 


1.12 
0.71 
0.85 


0.68 
0.25 
0.27 


14.97 


Bergell and Langstein 6 . . . 


14.60 
14.34 



1 Rietschel: Jahrb. f. Kinderh., hriv, 125. 

2 Ciccarelli: La Pediatria, 1908, vi, 12. 

3 Wroblewski: Ztschr. f. Physiol. Chem., 1898-99, xxvi, 308. 

4 Wroblewski: Ztschr. f. Physiol. Chem. 1898-99, xxvi, 308. 

5 Bergell and Langstein: Jahrb. f. Kinderh., 1908, lxviii, 568. 






HUMAN MILK, CHEMISTRY AND BIOLOGY 115 

The sulphur content of cow and human casein is as follows: 

Cow Casein Human Casein 

Liebig l Hempel * Liebig Hempel 

0.723 0.723 0.094-1.079 1.072 

According to these figures there is more sulphur in human than 
in cow's milk. They correspond closer to Wroblewski's figures 
than to those of Bergell and Langstein. It is still a disputed ques- 
tion whether the casein from different kinds of milk is identical 
or whether there are several different caseins. Recently Lang- 
stein and Edelstein found that the phosphorus content of human 
milk was 0.22 to 0.28% and that of cow's milk 0.85 to 0.87% and 
concluded that this was evidence that the two caseins were dif- 
ferent compounds. 

Bordet 2 showed that repeated injections of cow's milk into 
other animals caused a body to appear in the blood which precipi- 
tated the albuminous bodies of cow's milk and made them co- 
agulate. Wasserman 3 and others went a step further and showed 
that the blood serum of animals sensitized to cow's milk would 
precipitate the albuminous bodies in cow's milk, but would not 
precipitate those in human milk or the milk of other animals, 
and that the blood serum of animals sensitized to human milk 
precipitates the albuminous bodies in human milk and does not 
precipitate them in the milk of other animals. In other words, 
the blood serum of an animal may be sensitized to the albumins 
of a certain species of animal and react specifically to that species. 
These experiments can leave no doubt that the proteins of dif- 
ferent animals are different. 

Further investigations showed that casein, lactalbumin and 
globulin could be differentiated from one another by complement 
fixation and anaphylaxis experiments. 4 Milks of animals of one 
species can, therefore, be differentiated from the milk of animals 
of another species and the casein, globulin and lactalbumin of the 
same milk can be differentiated one from the other. 

Fat. — The fat in human milk is in a very fine emulsion. When 
the number of drops are counted in a counting chamber there are 

1 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

a Bordet: Ann. de PInst. Pasteur, 1899, xiii, 240. 

1 Wasserman: Verhandl. des 18 Congr. f. inn. Med., 1900, p. 501. 

4 Bauer and St. Engel: Biochem. Ztschr., 1911, xxxi, 46; Kleinschmidt: 
Monatschr. f. Kinderh., 1911-1912, x, 402. 



116 HUMAN MILK, CHEMISTRY AND BIOLOGY 

always more in human milk than in cow's milk. 1 The fat globules 
in human milk measure between 0.001 and 0.02 mm., while those 
in cow's milk measure 0.0016 to 0.01 mm. 2 Since the measure- 
ments given above show that the fat drops in human milk may be 
of greater diameter than those in cow's milk, it seems inconsistent 
that there should be a larger number in the former than in the 
latter. The explanation must be that the majority of fat drops 
in human milk are small and measure about 0.001 mm., while the 
majority of those in cow's milk must be closer to the upper limit 
and measure nearly 0.01 mm. 

The source of milk fat is, of course, the food. Fat is not ab- 
sorbed unchanged, though it may be re-converted into its original 
form after its passage out of the alimentary canal. Recent evi- 
dence shows that if large amounts of cotton seed oil are fed to 
cattle, some of its elements pass into the milk. 3 Arguing by 
analogy, it is possible that if given in sufficient quantities, un- 
changed fat may pass in a similar manner into human milk. 

Percentage and Quantity of Fat. — The figures as to the per- 
centage of fat and the total amount of fat in human milk vary 
considerably according to the various investigators and the meth- 
ods they pursue in obtaining their material. Engel's 4 mono- 
graph on human milk gives the most complete summary of the 
knowledge of this subject and is quoted freely in the following 
paragraphs. The percentage of fat is smallest at the beginning of 
nursing and largest at the end of nursing, the steepness of the 
curve depending on the total amount of milk taken at a nursing. 
When a small amount is taken, there is a sharp rise in the percent- 
age of fat, and when there is a large amount of milk taken, there 
is a more gradual rise. Although the percentage may increase 
regularly throughout the nursing, this is by no means the rule. 
The three curves taken from Engel give examples of how the 
percentages of fat may increase (see Chart). 

The percentage of fat in the first milk drawn varies between 1 
and 3% and that in the last milk taken between 6 and 10% . These 
figures may occasionally be even higher. There are cases on rec- 
ord in which there was more fat in the first part of the milk than 

1 Czerny and Keller: Des Kindes; Ernahrung, Ernahrungsstorungen, und 
Ernahrungstherapie, Leipzig and Wein, 1906, 1, 407. 

2 Leaves: Ztschr. f. physiol. Chem., 1894, xix, 369; Ruppel: Ztschr. f. Biol., 
1894, xxi, 1. 

3 Smith, Wells, Ewing: Bull. 122, Georgia Expt. Station, June, 1916. 

4 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 117 

in the last part and the curve is the reverse of the one just de- 
scribed. 1 

In pathological conditions the extremes of the percentage of 
fat are 0.1% 2 and 13.7%. 3 

The average fat content of the milk of ten wet-nurses (German) 
examined by Engel was 4.5%, and 119 women (Russian) ex- 
amined by Skvortzov, 4 3%. The amount of fat in the milk of 
the same women may vary from 25 to 100% in the same day at 
different nursings. When the intervals of emptying the breasts 
are long there is more milk and less fat. When all the milk of a 
woman is collected each day the average daily percentage is con- 
stant. This is true even if the total amount of milk is considerably 
increased. 

Quality of Fat. — When fat is separated from human milk by 
dissolving it in ether, it forms a yellowish-white mass similar, at 
room temperature, to butter. Human milk may be tinted yellow, 
as is cow's milk, by carotin and xanthophyll. The relative pro- 
portions of these two pigments is much more nearly equal than in 
the fat of cow's milk, according to Palmer and Eckles. 5 

1 Engel: Arch. f. Kinderh., 1906, xliii, 181. 

2 Moll: Arch. f. Kinderh., 1908, xlviii, 161. 

3 Engel: Arch. f. Kinderh., 1906, xliii, 194. 

4 Skvortzov: Russki Vratch ii, p. 1392; Ref. Chem. Abstracts, 1913, vii, 
No. 18. 

6 Palmer and Eckles: Jour. Biol. Chem., 1914, xvii, 191. 



118 HUMAN MILK, CHEMISTRY AND BIOLOGY 

CHART IV 

Chart from Engel. — The heavy black line indicates the increase in the per 
cent of fat when the milk is examined at frequent intervals during a single 
nursing. 



FAT 
* 

7 

6 
5 
4 
3 
2 
1 


WET - NURSE G 
29. VIII, '05.6 P.M. 


FAT 
t 

7 
6 
5 
4 
3 
2 
1 


WET - NURSE K 
22. VI. '05. 6 P.M. 


FAT 

t 

8 

7 
6 
5 
4 
3 
2 


WET - NURSE M 
13. V. '05 












































































































































































* 
* 


























4 


/ 












s 
/ 




























s t 


/ 










/ • 


























* 


* 
■ 


/ 






































y 


t 


/ 












• 


























* 





























































































































































































































































ft 6. 



150 



The melting point of human milk fat is between 30 and 34 C. 

The solidifying point is between 19 and 22.5 C. 

The specific gravity at 15 C. is 0.97. 1 

The fat of human is relatively poor in volatile fatty acids when 
compared with cow's milk. 

Volatile fatty acid, human milk, 2.5% of total fat. 

Volatile fatty acid in cow's milk, 27.0% of total fat. 

Among the volatile fatty acids have been demonstrated butyric, 
capronic, caprinic and caprylic acids. One-half of the non-volatile 
fatty acids are oleic acid, while among the solid fatty acids myristic 
and palmitic acids are found to be more abundant than stearic 
acid. 2 The large amount of oleic acid explains the relatively lower 
melting point and higher iodin value of human milk than of cow's 
milk. 

The iodin value of the fat in human milk varies within fairly wide 
limits, but is usually found at about 45. There are women in 

1 Ruppel: Ztschr. f. Biol., 1894, xxxi, 1; Laves: Ztschr. f. physiol. chem., 
1894, xix, 369; Sauvaitre: Ref., Malys. Jahresb. d. Tierchemie, 1903, xxxiii, 
324. 

2 Hammersten: English translation Text-book Physiological Chemistry, 
N. Y., 1909, p. 530. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 119 

whom it sinks to 32 and others in whom it is as high as 50. * Cer- 
tain observations go to show that the iodin value is in part depend- 
ent on the food. Goose fat, linseed oil 2 and iodized fats 3 have 
been demonstrated to pass from the food into the milk. 

Lactose. — Lactose, or milk sugar, is found only in the milk 
of animals. It is essentially the same in the milk of the woman, the 
cow, ass, rabbit, dog and horse. 4 There is evidence 5 which sug- 
gests strongly that lactose is formed from the dextrose in the 
blood. The quantity of lactose varies the least of all the elements/ 
of human milk. The amount of lactose in human milk is almost 
twice that in cow's milk, being on the average about 7%. The 
lowest percentage which has been found is 4.22 6 and the highest 
10.9%. 7 A few instances have been recorded in which the 
addition of sugar to the diet of the mother has increased the 
amount of sugar in the milk. This is, however, by no means the 
rule. 8 ' 

Lecithin. — It has been estimated that 100 c. c. of human milk 
contains 0.058 gm. of lecithin. 9 The question has been raised, 
however, whether the body that was quantitated as lecithin was 
not a result of the breaking down of some of the phosphorus- 
containing bodies by the chemical manipulations during the in- 
vestigation. 

Nuclein. — There is considerable debate as to whether human 
milk contains nuclein or not. Three cases which were examined 10 
showed an average per cent during one year as follows: 0.1302, 
0.1339 and 0.1305. The amount was inversely proportional to the 
quantity of the milk. 

Salts. — Total Ash: The average amount of ash in human milk 
is about 0.21%. n The amount of ash diminishes during the course 
of lactation just as does that of the protein. This is shown in 
the following from Camerer and Soldner: 

*Engel: In Sommerfeld's Handbuch der Milchkunde, Wiesbaden, 1909. 

2 Thiemich: Monatschr. f. Geburtsh. u. Gynak., 1899, ix, 515. 

3 Bendix: Deutsch. med. Wochenschr., 1898, xxiv, 223. 

4 Deniges: Contribution a Pe*tude des lactoses, Paris, 1892; Bonmartini: 
Rev. gen. du lait, 1906, ii, No. 1. 

5 Porcher: Biochem. Ztschr., 1909-10, xxiii, 370; Paton and Cathcart: 
Jour, of Physiol., 1911, xlii, 179. 

6 Pfeiffer: Verh. II, Versaml. d. Gesselsch. f. Kinderh., Wien, 1894, p. 131. 

7 Schlossmann: Arch. f. Kinderh., 1900, xxx, 324. 

8 Lust: Monatschr. f. Kinderh., 1913, xi, 236. 
9 Burow: Ztschr. f. Physiol. Chem., 1900, xxx, 506. 

10 Valenti: Chem. Zentralbl., 1909, i, 93. 

11 Camerer and Soldner: See Note 5, p. 94; Pfeiffer: Verh. d. gesellsch. f. 
Kinderh., Wien, 1894, p. 126. 



120 HUMAN MILK, CHEMISTRY AND BIOLOGY 

Days postpartum Per cent of ash 

8- 11 days 0.28 

29- 40 days 0.22 

60-140 days 0. 19 

170 days and later 0. 18 

The following table shows the percentage of the various salts in 
human milk to 100 parts of ash: 

TABLE 25 

Average Percentage Composition of Ash for the Different Periods 
(Holt, Courtney & Fales) 1 





CaO 


MgO 


P2O5 


Na 2 


K 2 


CI 


Colostrum 


14.2 
17.0 
23.3 
19.8 


3.5 
2.4 
3.7 
3.6 


12.5 
16.9 
16.6 
15.5 


13.7 

10.9 

7.2 

10.1 


28.1 
30.8 
28.3 
28.8 


20.6 


Transition 


22.9 


Mature 


16.5 


Late 


22.3 







Distribution 


df the Ash — Grams Per 100 c 


c. of Milk 








No. of 
Analyses 


Total 
Ash 


CaO 


MgO 


PzOf, 


NazO 


K2O 


CI 


Colostrum (1-12 days) 

Transition (12-30 days) 

Early mature (1— 4 months) .... 
Middle mature (4-9 months).. . 
Late milk (10-20 months) 


5 

6 

9 

8 

10 


.3077 
.2407 
.2056 
.2069 
.1978 


.0446 
.0409 
.0486 
.0458 
.0390 


0101 
.0057 
.0082 
.0074 
.0070 


.0410 
.0404 
.0342 
.0345 
.0304 


.0453 
.0255 
.0154 
.0132 
.0195 


.0938 
.0709 
.0539 
.0609 
.0575 


.0568 
.0580 
.0351 
.0358 
.0442 



The composition of the ash of human milk is, according to 
Soldner 2 as shown in Table 26. 



TABLE 26 
Composition of Ash op Human Milk (From Engel) 





100 gm. milk contains, 
milligrams 


100 gm. ash contains, 
milligrams 




First milk 


End milk 


Average 


First milk 


End milk 


Average 


K20 


100.8 

44.8 

37.6 

5.4 

0.22 

32.10 

9.6 

71.7 


63.4 

17.6 

38.1 

5.2 

0.12 

28.8 

7.2 

34.2 


88.4 

35.7 

37.8 

5.3 

0.2 

31.0 

9.0 

59.1 


32.5 

14.5 

12.1 

1.7 

0.07 

10.40 

3.1 

23.1 


31.9 
8.9 

19.2 
2.6 
0.06 

14.50 
3.6 

17.3 


32.4 


Na 2 

CaO 


13.1 
13.9 


MgO 

Fe 2 3 

P 2 5 

S0 3 


1.9 

0.07 

11.40 

3.3 


CI 


21.7 







1 Holt, Courtney, Fales: Am. Jour. Dis. Ch. 1915, x, 229. 

2 Soldner: From Sommerfeld's Handbuch, etc., p. 800. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 121 

These figures show that the ash varies in amount, as well as other 
milk components, according to whether the sample of milk is 
taken at the beginning or at the end of nursing. It is obviously 
just as necessary to obtain milk under the same conditions and 
with the same precautions when the salts are to be investigated 
as when the other food components are to be studied. 

Calcium. — A large number of analyses show wide individual 
variations between 0.03 and 0.08%, with an average of 0.042 to 
0.044%. The daily variations may amount to as much as 0.02%. 
The calcium content decreases as the period of lactation pro- 
gresses. The amount of calcium cannot be increased by feeding 
the mother with calcium salts. 1 

Iron. — Friedjung 2 found from 3.52 to 7.21 mg. iron in a liter 
of human milk. This gives an average of 5.09 mg. This figure is 
somewhat higher than those given by Camerer and Soldner 3 
and Bahrdt and Edelstein, 4 who found between 1.215 and 2.93 mg. 
per liter. The iron content of the milk is dependent on the general 
condition of the woman. It is higher in healthy individuals and 
lower in those under par. A regular decrease in the amount of iron 
during lactation has not been demonstrated. Neither have in- 
vestigations of the iron content of the milk in pathologic condi- 
tions of either the mother or the baby given any figures of clinical 
significance. 

Chlorids. — Freund 5 found that 1,000 c. c. of the milk of the 
same woman contained, on four successive days: 0.488, 0498, 
0.433 and 0.456 NaCl. Bunge obtained similar results. 

Phosphorus. — There is a great difference in the form in which 
phosphorus is present in human and in cow's milk. Three-quarters 
of that in human milk is in organic combination, while only one- 
quarter of the phosphorus in cow's milk is in organic combination. 
The phosphorus which is in organic combination is considered by 
many to be in the form of lecithin and nucleon, which are present 
in larger amounts in human than in cow's milk 6 (see lecithin and 

1 Bahrdt and Edelstein: Jahrb. f. Kinderh., 1910, lxxii, 16; Schabad: Jahrb. 
f. Kinderh., 1911, lxxiv, 511. 

2 Friedjung: Arch. f. Kinderh., 1901, xxxii, 58; Jolles and Friedjung: Arch, 
f. exper. Path. u. Pharm., 1901, xlvi, 247 (entire literature to date). 

3 Camerer and Soldner: Ztschr. f. Biol., 1900, xxxix, 190; 1903, xliv, 71; 
1905, xlvi, 371. 

4 Bahrdt and Edelstein: Ztschr. f. Kinderh., 1910, 1, 182. 

6 Freund: Chlor. und Stickstof in Sauglings organisms, Jahrb. f. Kinderh., 
1898, N. F., xlviii, 137. 

6 Siegfried: Ztschr. f. Phys. Chem., 1897, xxii, 575; Whittmaack: Ztschr. 
f. physiol. Chem., 1897, xxii, 567; Burow: Ztschr. physiol. Chem., 1900, xxx, 
495. 



122 HUMAN MILK, CHEMISTRY AND BIOLOGY 

nucleon); 41.5% of the total phosphorus in human milk is in the 
form of nucleon phosphorus and only 6% in cow's milk. 1 Because 
of the larger amount of casein and calcium phosphate which it 
contains, cow's milk is much richer in phosphorus than human 
milk. The relation of P2O5 to N is 1:54 in human milk, and 
1 :27 in cow's milk. 2 Keller 3 found that one liter of milk con- 
tained of P2O5 



Grams P2O5; 



0.40 

0.44 

0.377 

0.452 

0.353 



ft QQfi ) 

A " OQO I The same woman. 
The mixed milk of diff erent ° • d8J J 
wet-nurses. 



Sikes 4 gives 0.297 P2O5 to the liter as an average of figures in 
the first three weeks of life. The amount varies between 0.14 and 
0.522. Schlossmann 2 gives as an average 0.461 P2O5 per liter. 
The phosphorus content of the milk depends in good part on the 
casein content of the milk. 

Citric Acid. — The average amount of citric acid in human milk 
is 0.05%. 5 

Caloric Value. — The caloric value of one liter of human milk is 
782 calories. 6 

Unknown or Unidentified Substances. — Meigs and Marsh 7 re- 
port the presence of substances of unknown nature which contain 
little or no nitrogen and are soluble in alcohol and ether. Human 
milk immediately after the colostrum stage contains 1% of these 
unknown substances, while milk from the middle period of lacta- 
tion contains about 0.5%; cow's milk from the middle period of 
lactation contains about 0.3% of these substances. 

Viscosity. — There is in most cases a regular decrease in the 
viscosity of milk during the first twenty-four hours postpartum. 
There is no difference between the viscosity in normal or abnormal 
cases then or later. The electrical conductivity is almost always 
increased in abnormal cases. This increase is least when there is 
albuminuria and greatest when the supply of milk is scanty. There 
is a regular decrease in the electrical conductivity during the first 

1 See note 6, ante, page 121. 

2 Schlossmann: Arch. f. Kinderh., 1905, xl, 1. 

3 Keller: Arch. f. Kinderh., 1900, xxix, 1. 
4 Sikes: Jour. Physiol., 1906, xxxiv, 464. 

6 Scheibe: Quoted by Engel. See note 5, p. 96. 
"Schlossmann: Archiv. f. Kinderh., 1900, xxx, 288. 

7 Meigs and Marsh: Jour, of Biol. Chem., xvi, No. 1. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 123 

week postpartum. 1 The degree of viscosity depends on the amount 
of solids in the milk especially of casein. 2 



VARIATIONS IN THE COMPOSITION OF HUMAN MILK 

Table 27, page 112, shows the lowest and highest figures given 
by various authors. These figures show that the variations in the 
percentage of fat are the greatest, but that there are considerable 
differences in the percentages of the other components of human 
milk. There are no figures in literature in which the percentages 
of all components are high or all low. Usually, when one com- 
ponent is increased, another is diminished. 

The average composition of human milk is usually given as 
follows: Fat, 4%; lactose, 7%; protein, 1.50%; (casein 42%, 
filterable nitrogen including lacatalbumin, globulin and unknowm 
bodies 58%) ; salts, 0.21%. The following table shows the varia- 
tion in composition during the different periods of lactation. 

Pekcentage Composition op Woman's Milk by Pebiods 3 



Period 


No. of 
Analyses 


Fat 


Sugar 


Protein 


Casein 


Albu- 
min 


Ask 


Total 
Solids 


Colostrum, (1-12 da.) . . . 
Transition, (12-30 da.) . . 

Mature, (1-9 mos.) 

Late, (10-20 mos.) 


5 
6 

17 
10 


2.83 
4.37 
3.26 
3.16 


7.59 
7.74 
7.50 

7.47 


2.25 
1.56 
1.15 
1.07 


".43 
.32 


"'.72 
.75 


.3077 
.2407 
.2062 
.1978 


13.42 
13.39 
12.16 
12.18 



The previous tables show that human milk may vary widely in 
its composition from these figures and still be normal. 

1 Polenaar and Phillipo: Ztschr. f. Pathol., ix, 138. 

s Oertel: Dissertation, Leipzig, 1908, Ref. Arch. f. Kinderh., 1909, li, 282. 

8 Holt, Courtney & Fales: Am. Jour. Dis. Ch., 1915, x, 229. 



124 HUMAN MILK, CHEMISTRY AND BIOLOGY 

TABLE 27 
Variations in Composition of Human Milk (from Czerny and Keller) 





Fat, 


Sugar, 


Protein* 


Ash, 


Solids, 




per cent. 


per cent. 


per cent. 


per cent. 


per cent. 


Pf eiffer « 


0.75-9.05 


4.22- 7.65 


1.049-3.04 


0.104-0.446 


8.23-15.559 


Johannessen 












and Wang 2 . 
V. and J. S. 


2.7 -4.6 


5.9 - 7.8 


0.9 -1.3 
















Adriance 3 . . . 


1.31-7.61 


5.35- 7.95 


0.23 -2.60 


0.09 -0.28 


9.19-15.31 


Guirand 4 


1.75-6.18 


6.7 - 7.7 


0.85 -1.4 


0.10 -0.27 


11.2 -16.3 


Camerer and 












Soldner 6 . . . . 


1.28-5.77 


5.35- 7.52 


0.82 -1.86 


0.11 -0.36 


9.41-14.11 


Schlossmann 6 . 


1.65-9.46 


5.2 -10.90 


0.56 -3.4 







* Nitrogen times 6.25. 

Influence of Food on Quantity and Composition of Milk. — 

The fat in the milk may diminish when the mother is underfed. 7 
If more fat is given in the diet of such an underfed woman, the 
fat in the milk will increase up to a certain point. If, however, 
large amounts of fat are given to women who already have suffi- 
cient quantities of fat in the food, there is only a temporary in- 
crease in the fat in the milk in spite of the excessive fat in the diet. 8 
Czerny and Keller 9 conclude that the milk of nursing mothers 
cannot be permanently influenced by the food, except in those in- 
stances in which they do not get sufficient food, i. e., when they 
are partially starved. The quantity of the milk cannot be in- 
creased at will by increasing the amount of food or drink. There 
are a few instances on record in which the addition of sugar to the 
diet of a nursing woman has increased the amount of sugar in the 
milk. Such an increase is, however, by no means the rule (see 
lactose). 

Hoobler 10 recently studied the food of wet-nurses to determine 

1 Pf eiffer: Verhandl. d. II Vers. d. Gesellsch. f. Kinderh. in Wien, 1894, 
p. 131. 

2 Johannessen and Wang: Ztschr. f. Physiol. Chem., 1898, xxiv, 499. 

3 Adriance, V. and J. S. : Arch, of Pediatrics, 1897, xiv, 27. 

4 Guirand: These de Bordeaux, 1897. 

5 Camerer and Soldner: Ztschr. f. Biol., xli, N. F., 18, p. 280. 
Schlossmann: Arch. f. Kinderh., 1900, xxx, 324. 

7 Engel and Plaut: Munchen. med. Wochenschr., 1906, liii, 1158. 

8 Albert: Ref. Malys. Jahresb. f. Thierchemie, 1899, xxix, 253; Henriques 
and Hansen: Jahresb. f. Thierchemie, 1899, xxix, 68. 

9 Czerny and Keller: Des Kindes; Ernahrung, Ernahrungsstorungen, und 
Ernahrungstherapie, Leipzig and Wien, 1906, 1, 407. 

10 Hoobler: Am. Jour. Dis. Ch., 1917, xiv, 105. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 125 

which form of food protein was the most economical and avail- 
able in forming milk protein. He found that there should be at 
least one part of food protein to six parts of food carbohydrate, 
and fats for the best production of milk. He also found that 
animal protein and especially that from milk was more suitable 
than vegetable proteins, in supplying nitrogen for milk. A diet 
of fruits, cereals, and vegetables does not give sufficient available 
protein, and causes a severe drain on the tissues of the mother. 
Nuts, however, added to this diet may be used to supply the deficit. 

GALACTAGOGUES 

Schafer and MacKenzie * found that the posterior lobe of the 
pituitary body of the ox and the corpus luteum of sheep both act 
as galactogogues when injected into cats and dogs. Hammond 2 
found that the injection of pituitary extract into lactating goats 
increased the amount of milk for twenty-four hours. The amount 
decreased below the normal during the next twenty-four hours, 
however, so that the average of the two days was the normal 
amount. 3 Gavin did not find the pituitary extract affected the 
quantity of milk in cows. MacKenzie and others 4 believe that 
the mammary gland can be stimulated by the posterior lobe of the 
pituitary body, the pineal body and the corpus luteum. The action 
of the former is supposed to be the most powerful. Inhibitory sub- 
stances are said by some observers to be produced by the fetus, 
placenta, spleen, pancreas, adrenals and thyroid. Aschner and 
Grigori, 5 on the other hand, say that the pulp of placenta or of 
the fetus, or their watery extracts, cause a true secretion of milk 
in virgin animals, and that the body which causes this secretion is 
(contrary to Starling's contention) destroyed by alcohol and heat. 
Basch 6 reports that substances present in the placenta when in- 
jected into animals will bring back the secretion of milk after it 
has stopped. Hammett and McNeille 7 recently investigated anew 
the influence of ingested dessicated placenta on the character and 
secretion of human milk as well as its influence on the growth of 
the infant. It is not apparent, however, that the changes which 

1 Schafer and MacKenzie: Proc. Roy. Soc, London (B), 1911, Ixxiv, 16. 

2 Hammond: Quart. Jour. Exper. Physiol., 1913, vi, 311. 

3 Gavin: Quart. Jour. Exper. Physiol., 1913, vi, 13. 

4 MacKenzie: Quart. Jour. Exper. Physiol., 1911, iv, 305; Ott and Scott: 
Therap. Gaz., 1911, xxxv, 689. (Experiments on goats.) 

6 Aschner and Grigori: Arch. Gyn., xciv, No. 3. (Guinea-pigs were used.) 

6 Basch: Munchen. med. Wochenschr., 1911, lviii, 2266. 

7 Hammett and McNeille: Jour. Biol. Chem., 1917, xxx, 145. 



126 HUMAN MILK, CHEMISTRY AND BIOLOGY 

they attributed to its use were any greater than those which 
might be normally expected. Wolf * injected milk into nursing 
women and found that there was an increase in the amount of 
milk secreted. Chatin and Rendu 2 repeated Wolf's work with 
eight women. They gave thirteen injections of milk with the re- 
sult that in eight instances the curve of milk secretion remained 
stationary or became slightly lowered. In the five remaining in- 
stances, there was a slight increase in the amount of milk secreted 
after the injection of milk. This increase was, however, always in 
association with other factors, such as a change in the number of 
nursings, or a greater demand on the part of the infant. They be- 
lieve that the latter were the cause of the increase and not the 
former. 

There is much evidence to show that substances secreted in the 
ovary cause the growth of the breast glands at puberty. Cramer 3 
believes that it has no influence on the hyperplasia of pregnancy, 
while Basch, 4 on the other hand, attributes the increase in size of 
the breast glands to a secretion in the ovary. The blood of a 
pregnant animal injected into a lactating animal has no influence 
on the secretion of milk. 5 After summing up all the evidence on 
the subject, one is forced to conclude that there are no artificial 
means of increasing the secretion of milk. 

FOREIGN BODIES IN HUMAN MILK 

Certain drugs have been proved to be excreted in human milk 
after they have been taken by the mother, but these are present 
only in traces. They are potassium iodid, sodium salicylate, anti- 
pyrin, mercury, 6 aspirin, calomel, arsenic, bromids, 7 urotropin, 8 
and to a certain extent those bodies which are soluble in fat, such 
as the iodinized oils. 6 Acetanilid occasionally appears in human 
milk after the administration of a dose of 4 grains in from seven 
to fifteen hours. The quantity eliminated, however, is so minute 
as to be harmless to the nursing infant. 9 

1 Wolf: Zentralbl. f. Biochem. u. Biophys., 1913, xiv, 224. 

2 Chatin and Rendu: Lyons m6d., 1912, cxviii, 161. 

3 Cramer: Munchen. med. Wochenschr., 1909, lvi, 1521. 

4 Basch: Munchen. Med. Wochenschr., 1911, lviii, 2266. 

6 D'Errico: La Pediatria, Abstr. in Jahrb. f. Kinderh., 1910, xxii, 504. 
•Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 

p. 810. 

7 Bucura: Ztschr. f. Exper. Path. u. Therap., 1907, iv, 398. 

8 Schmidt and Schroter: Zentralbl. f. d. ges. Physiol, u. Path. Stoffwechsels, 
1910, v. 129; Rieder: Monatschr. f. Kinderh., 1912, xi, 80. 

• Stevenson: Mich. State Med. Soc, Jour., 1914, xiii, p. 230. 






HUMAN MILK, CHEMISTRY AND BIOLOGY 127 

Alcohol is found in human and cow's milk in minimal amounts 
after the ingestion of very large amounts, but not after the taking 
of small amounts. 1 It is possible that opium, in the form of mor- 
phin, and atropin may be excreted in human milk, since it has been 
shown that they go over into the milk of animals. 2 They have not 
as yet been found in human milk. 

Salvarsan injected into the syphilitic mother is excreted in the 
milk and after such treatment the syphilitic suckling frequently 
shows remarkable improvement; in some instances the infant has 
suddenly died, so soon after the institution of treatment that death 
seemed to result from treatment. 3 It is evident that such treat- 
ment may not be entirely free from danger. 



INFLUENCE OF VAKIOUS PHYSIOLOGICAL AND PATHOLOGICAL CON- 
DITIONS ON THE SECRETION OF MILK 

Nervous Impressions. — " Fright, grief, passion, excessive sexual 
indulgence, or any great excitement may entirely arrest the secre- 
tion, or if not arrested the milk may be so altered in composition 
as to make the child actually ill." (Holt.) Although such phe- 
nomena have been observed clinically, there are no chemical ob- 
servations which tell exactly what the chemical changes are under 
such circumstances, except those given by Rotch. 4 

Menstruation. — Rotch 4 gives the illustration, shown in the 
next table of a case in which the milk was examined during and 
after menstruation. 

TABLE 28 
Effect of Menstruation on Breast-Milk 





Fat 


Lactose 


Protein 


Salts 


Water 


Second day of menstrua- 
tion; child's stools loose. 
Per cent 


1.37 

2.02 
2.74 


6.10 

6.55 
6.35 


2.78 

2.12 

0.98 


0.15 

0.15 
0.14 


89.60 


Seven days after menstru- 
ation; bowels regular. 
Per cent 


89.16 


Forty days later; child gain- 
ing rapidly. Per cent 


89.79 



1 Voltz: Biochem. Ztschr., 1913, lii, 73. 

'Czerny and Keller; Des Kindes Ernahrung, Ernahrungsstorungen, und 
Emahrungstherapie, Leipzig and Wein, 1906, 1, 407. 

* Jesionek: Munchen. med. Wochenschr., 1911, lviii, 1169; Jeanselme: Ann. 
de gynec. et d'obst., 1911, 2 Ser., viii, 394; Wolbarst: Am. Medicine, 1911, 
xvii, 486. 

4 Rotch: Pediatrics, Philadelphia and London, 1901, p. 144. 



128 HUMAN MILK, CHEMISTRY AND BIOLOGY 

Bendix * examined the milk of eight women before, during and 
after menstruation. He concluded that such variations as he 
obtained were not outside of the normal physiological limits. 

Grulee and Caldwell 2 found that the quantity of milk varied 
with menstruation. There was a period of increase of breast-milk 
commencing with the first day of menstruation and lasting from 
that day to two weeks, after which the amount diminished, reach- 
ing its lowest point four to seven days previous to the next men- 
strual period. 

Uremia. — Finizio 3 studied the protein content of human milk 
and found that it increased only in nephritis and mild uremia 
(see residual nitrogen). Thiemich 4 concluded, after reviewing the 
literature, that this increase did not affect the nursing infant so 
long as the quantity of the milk and the health of the mother were 
normal. 

Beriberi. — The milk of mothers with beriberi paralyzes the 
heart of frogs quicker than does Ringer's solution. 5 Clinically, 
such milk is dangerous for the infant and causes the disease. The 
poisons are said to be toxins. They are excreted in greater quan- 
tities in the milk, if the mother is constipated. 6 

Bile. — Bile has been detected in the fat of the milk of a patient 
who developed jaundice after each confinement. The fat con- 
tained urobilin and small amounts bilirubin, while there were no 
bile components in the aqueous liquid. 7 

DIFFERENTIATION OF HUMAN FROM OTHER MILKS 

Umikoff's Reaction. — When 5 c. c. of milk are warmed on a 
water bath at 60 C. with 2.5 c. c. of a 10% solution of ammonium 
hydrate for from fifteen to twenty minutes, a reddish violet color 
appears if human milk is used, while there is no change with cow's 
milk. 

Davidsohn's Reaction. — See fat-splitting ferment. 

Moro's Reaction. 8 — Moro found that a 1% aqueous solution of 
neutral red turns human milk yellow and cow's milk purple. The 

1 Bendix: Charit6-Ann., 1898, xxiii, 412; Baueberg: Zeitschr. f. Kinderh., 
1913, vi, 424. 

2 Grulee and Caldwell: Am. Jour. Dis. Ch., 1915, ix, 374. 

3 Finizio: Pediatria, 1908, vi, 401. 

4 Thiemich: Monatschr. f. Geburtsch. u. Gynak., viii, 521; ix, 504. 

5 Guerrero and Cavieres: Bull. Manila Med. Soc, 1912, iv, 167. 

6 Inagaki and Nakayama: Abstr. in Brit. Jour. Dis. Child., 1910, vii, 467. 

7 Marck: Pharm. Weekblad., 1907, xliv, 153. 

8 Moro: Munchen. med. Wochenschr., 1912, lix, 2553. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 129 

addition of one drop of the stain to a teaspoonful of drawn breast- 
milk changes it to a reddish purple at once, if the milk has been 
kept too long and is unfit for use. 

Bauer's Reaction. 1 — Bauer found that the addition of one drop 
of a 0.25% aqueous solution of neutral blue sulphate (Grubler) to 
from 2 to 3 c. c. of human milk turns the milk violet-blue. When 
added to cow's milk it turns it greenish-blue. When about five 
times as much ether is added and the mixture is shaken violently, 
the color is extracted from human milk but persists in cow's 
milk. 

Tugendreich's Reaction. 2 — Equal amounts of a 1 to 2% aqueous 
solution of silver nitrate and milk are mixed, shaken and quickly- 
boiled for three minutes. Human milk changes in color to coffee- 
brown or brownish-violet, while cow's milk does not. 

FERMENTS (ENZYMES) 

A great deal of importance has been attached to the ferments 
or enzymes of milk, especially in the discussions as to whether 
raw or boiled milk is the more digestible for infants and in con- 
nection with the diseases of metabolism, such as scorbutus and 
rachitis. 

The study of the ferments is open to error because of the pres- 
ence of bacteria in milk. It is almost impossible to obtain a 
truly sterile milk and to keep that milk sterile for any length of 
time. The use of toluol or chloroform to keep the milk sterile may 
modify or destroy the enzymes, while sterilization by heat de- 
stroys the enzymes. Since the action of bacteria may cause all the 
phenomena produced by the ferments in milk, the action of bac- 
teria must always be excluded. 

The Proteolytic Ferments. — (a) Casease has the property of 
converting casein into soluble albumin. 3 It is found in human and 
cow's milk. 

(b) Pespin and Tryspin: Both of these ferments are supposed to 
be present in cow's and human milk (Spolverini 4 ), the one acting 
in acid media and the other in alkaline surroundings. Other in- 
vestigators 5 could not convince themselves that there were any 
such ferments in demonstrable quantities. The proteolytic fer- 

1 Bauer: Monatschr. f. Kinderh., 1912-13, orig. xi, 474. 

2 Tugendreich: Berl. klin. Wochenschr., 1911, xlviii, No. 1, p. 224. 
3 Raudnitz: Ergebn. d. Physiol., 1903, ii. 

4 Spolverini: Arch, de med. d. Enf., 1901, iv, 705. 

5 Moro: Jahrb. f. Kinderh., 1902, N. F., lvi, 391; Hippius: Jahrb. f. Kinderh., 
1905, M, 365. 



130 HUMAN MILK, CHEMISTRY AND BIOLOGY 

ments, according to Freeman 1 are not affected by heating for one- 
half hour at 65 C. (149 F.) or for one hour at 60 C. (140 F.) They 
are destroyed by boiling. 

(c) Fibrinogen : Schlossmann 2 observed that human milk caused 
the coagulation of the hydrocele fluid from a young infant, while 
cow's milk did not. This observation was subsequently con- 
firmed. 3 It was shown that this ferment is not destroyed by heat 4 
and that it is sometimes found in cow's milk. 5 

Carbohydrate-Splitting Ferments. — Amylase 6 has the power of 
splitting starch into dextrin and of continuing the process until a 
very little of it is converted into maltose. 7 This ferment is pres- 
ent in human milk. According to some investigators it is not 
present in cow's milk. Others 8 using different methods, always 
find it in cow's milk. The action of amylase is increased by the 
addition of peroxid of hydrogen. 9 It is destroyed at the tem- 
perature of 75 C. (167 F.), perhaps at a somewhat lower 
one. It appears to pass into the whey when the casein is 
precipitated. 

A disaccharid-splitting ferment has been reported in cow's milk 
which is capable of splitting lactose; it may also be present in 
human milk. 10 It is not changed by heating for one-half an hour 
at 65 C. (149 F.) or for one hour at 60 C. (140 F.), but is weakened 
by heating for a short time at 70 C. (158 F.) and is destroyed at 
75 C. (167 F.). 11 

Fat-Splitting Ferment. — This ferment decomposes neutral fats 
into fatty acids and glycerin. 12 It is found in both human and 
cow's milk. This ferment in human milk breaks tributyrin into 
butyric acid in a very few minutes, but in cow's milk only after 
many hours. This test may be used to differentiate raw human 
milk from boiled human milk, and raw and boiled cow's milk. 13 

1 Freeman: Jour. Am. Med. Assn., 1907, xlix, 1740. 

2 Schlossmann: Verhandl. d. xviii Versamml. Gesellsch. f. Kinderh., Ham- 
burg, 1901. 

3 Moro: Wien. klin. Wochenschr., 1902, xv, 121. 

4 Moro and Hamburger: Wien. klin. Wochenschr., 1902, xv, 121. 

5 Bernheim-Karrer: Zentralbl. f. Bakt., 1902, xxxi, 388. 

6 Diastase, zymase, diastatic ferment. 

7 Bechamp: Compt. rend., Acad. d. sc, 1883, 96. 
8 Konig: Milchwirtschol: Zentralbl., 1907, iii. 
9 Lagane: Compt. rend., Acad. d. sc, 156, 1941. 

i° Stoklasa: Arch. f. Hyg., 1904, 1, 165. 

11 Freeman: Jour. Am. Med. Assn., 1907, xliv, 1740. 

12 Marfan and Gillet: Monatschr. f. Kinderh., 1902-3, 1, 57; M loc. cit. t 
note 3); Hippius (loc. ciL, page 117). 

13 Davidsohn: Ztschr. f. Kinderh., 1913, viii, 14. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 131 

The ferment is, therefore, present in relatively large amounts in 
human milk, but only in traces in cow's milk. Heating to 
60 C. (140 F.) does not affect it, while 64 C. (147.2 F.) de- 
stroys it. 

Salol-Splitting Ferment. — It was found that human milk had 
the power of splitting salol. This power was not destroyed by 
heating to 100 C. (212 F.). Further investigation showed that this 
phenomenon was not due to a ferment, but was purely chemical. 
Salol is split in an alkaline medium of the same alkalinity as human 
milk. When cow's milk is brought to the same grade of alkalinity 
it also will split salol. 1 

Oxydase and Reductase. — (a) Super oxidase: Superoxidase is 
the name given to the ferment which reduces peroxid of hydrogen 
into water and oxygen. It acts best at about 37 C. (98.6 F.) and is 
destroyed at about 68 C. (154.4 F.). During centrifugalization it 
rises with the cream. 2 There is a large amount both in human milk 
and cow's milk. 

(b) Peroxidases: Peroxidases hasten the oxidation of such bodies 
as tincture of guaiac. They pass into the cream during centrifugali- 
zation and in fractional precipitation are precipitated along with 
the globulins. 3 There is no definite temperature at which this 
enzyme is destroyed, because the rate of heating modifies the 
results. 4 

(c) Reductase: When reductase comes in contact with sulphur 
and water it converts the sulphurin to the corresponding hydrids; 5 
it also reduces methylene blue 6 and decolorizes Schardinger's 
reagent. 7 It is stronger in cream than in skimmed milk 2 and is 
precipitated with the casein. It is found in both human and cow's 
milk. Its action with Schardinger's reagent 8 is used in differen- 
tiating raw from boiled milk. Heating milk to between 70 C. 
(158 F.) and 80 C. (176 F.) stops the reaction. Reductase is most 
active between 40 C. (104 F.) and 55 C. (131 F.). 

1 Demoulieres: Jour, de pharm. et chim., 1903, xvii, Miele and Willen: 
Compt. rend., Acad. d. sc, 1903, cxxxvii. 

2 Hecht and Friedjung: Arch. f. Kinderh., 1903, xxxvii, 177. 
3 Raundnitz: Pfaundler and Schlossmann: Diseases of Children, Philadel- 
phia and London, 1908, i, 308. 

4 Van Eck: Chem. Weckblad, viii, 692, ref. Chem. Abstr., Jan. 10, 1912. 
6 Rey: Pailhade quoted from Possi-Escot: Etat actuel sur les oxydases et 
reductases, Paris, 1902. 

8 Possi-Escot (see note 8, page 118). 

7 Smidt: Hyg. Rundschau, 1904, xiv, 1137; Hecht: Arch. f. Kinderh., 1904, 
xxxviii, 349. 

8 Five c. c. saturated alcohol solution of methylene blue, 5 c. c. formalin, 
190 c. c. water. 



132 HUMAN MILK, CHEMISTRY AND BIOLOGY 

TRANSMISSION OF TOXIC BODIES AND IMMUNITY THROUGH MILK 

Toxins. — Sonnenberger * concluded from his investigations that 
milk is not only a secretion but an excretion and that, therefore, 
many vegetable poisons in the food of animals may go over in 
the milk. Among these poisons are alkaloids, glycosids and 
amids, as well as volatile and ethereal oils, and dibasic organic 
acids. 

Toxins may be formed as the result of the metabolism of certain 
bacteria, may be produced by plants, or may come from the 
secretions or body components of certain animals. 

Antibodies. — Ehrlich 2 was the first to show that immunity 
could be transmitted to the infant through the milk. The fact that 
breast-fed infants seem to be less liable to such diseases as measles, 
scarlet fever, mumps and typhoid fever is used by many as an 
argument that immunity is transmitted through the breast- 
milk. Recently emphasis has again been laid on the greater im- 
munity of the breast-fed infant to infection, than the artificially- 
fed. 3 

Antitoxin. — It has been shown that in animals immunity to 
the bacillus of anthrax and the pneumococcus is transmitted by the 
mother to the young. It is impossible to say, however, whether 
this immunity is transmitted through the milk or is acquired dur- 
ing intrauterine fife. 4 Ehrlich 2 concluded from his researches that 
artificial immunity can only come through the milk of the mother. 
When a mouse which was born of a normal mother, which was not 
immunized, was fed by a mouse immunized with antitoxin, the 
suckling developed immunity. The amount of antitoxin that 
passes from the mother through the milk to the suckling is between 
one-fifteenth and one-thirtieth of the total amount in the mother, 
depending on the amount of lactalbumin and globulin that her 
milk contains. 5 It was impossible to immunize the human infant 
by feeding it with horse antitoxin, but when its own mother or the 
wet-nurse was immunized with horse antitoxin the immunity was 

1 Sonnenberger: Therap. Monatschr., 1901, xv, 6; Sonnenberger: bod 
Naturforschersamml., Miinchen, 1899. 

2 Ehrlich: Ztschr. f. Hyg. u. Infectionskr., 1892, xii, 183. 

3 Kleinschmidt: Monatschr. f. Kinder., 1913, xii, 423; Czerny, Med. Klinic, 
1913, vii, 895. 

4 Chauveau: Ann. de PInst. Pasteur, 1888, ii, 66; Klemperer: Arch. f. Exper. 
Pathol, u. Pharm., 1892-93, xxxi, 356. 

5 Brieger and Ehrlich: Ztschr. f. Hyg., 1893, xiii, 336; Brieger and Cohn: 
Ztschr. f. Hyg., 1893, xv, 1; Wassermann: Ztschr. f. Hyg., xviii; Ehrlich and 
Wassermann: Ztschr. f. Hyg., 1894, xviii, 235; Romer: Berl. klin. Wochenschr., 
1901, xlvi, 209; Kayser: Ztschr. f. klin. Med., 1905, lvi, 17. 



HUMAN MILK, CHEMISTRY AND BIOLOGY 133 

transferred through the milk to the nursing infant even as early as 
the fourth week of life. 1 Immunity can, therefore, be transferred 
by way of the milk or albumins of the same species, but not by 
those of another species. 

Agglutinins. — The same question comes up in studying the 
agglutinins as in the case of the antitoxins as to whether the 
property of agglutination is acquired during intrauterine life or 
passes through the milk. 

The evidence that it may be transferred by the mother through 
her milk to the infant is in part positive and in part negative. 
Romer, 2 after summing up the literature, concludes that agglu- 
tinins may be transferred in the milk. The agglutinins in the milk 
of the mother are more easily absorbed from the infant's gastroin- 
testinal canal than those in the milk of animals. 

Bactericidal Substances. — The fact that the blood of infants 
that are nursed at the breast contains stronger bactericidal sub- 
stances than that of those fed on the bottle 3 is evidence in favor of 
these substances being carried in the milk, in spite of the fact that 
they cannot be demonstrated in the milk itself. 

Hemolysin. — Hemolysin has recently been demonstrated as a 
normal constituent of the different kinds of milk. 4 It is absent 
from colostrum in the majority of cases tested on the second day 
postpartum. 5 Hemagglutinins are found in human milk that 
react differently toward the blood corpuscles of different species of 
animals. 6 

Opsonin. — The milk is poorer in opsonins than the blood serum 
of the mother 7 while the colostrum contains more than the 
milk. 8 

Hypersensibility. — Hypersensibility (sensitization) toward va- 
rious poisons and albumins may pass over in the milk to the infant 
and be absorbed. 9 

J Salge: Jahrb. f. Kinderh., 1904, lx, 1. 

2 Romer: Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 492. 
*Moro: Jahrb. f. Kinderh., 1902, lv, 396. 

4 Pfaundler and Moro: Ztschr. f. Exper. Pathol, u. Therap., 1907, iv, 451. 
5 Kolff and Noeggerath: Jahrb. f. Kinderh., 1909, lxx, 701. 
8 Zubezycki and Wolfsgruber: Deutsch. med. Wochenschr., 1913, xxxix, 
210. 

7 Turton and Appleton: Reference, Deutsch. med. Wochenschr., 1907, xxxiv. 

8 Tunnicliff: Jour. Infect. Dis., 1912, xi, 347. 

9 Otto: Munchen. med. Wochenschr., 1907, liv, 1665. 



CHAPTER XI 
CLINICAL CONSIDERATIONS AND TECHNIQUE 

The contraindications to nursing have already been mentioned, 
and the ability of women in general to nurse their babies has al- 
ready been referred to. Far more women are able to nurse their 
babies than is generally supposed. As a matter of fact, very few 
women are entirely unable to nurse. The so-called inability to 
nurse is in many instances unwillingness rather than inability. 
Many women are, however, thought to be unable to nurse when 
they really are able. The attempt at nursing is not infrequently 
given up too soon because the milk is late in appearing. The 
production of milk begins in two ways: either the quantity of milk 
slowly, but gradually, increases or, after a very small secretion in 
the beginning, there is a very sudden increase, which is often 
spoken of as the "running-in" of the milk. The supply of milk is 
often considered insufficient when the "running-in" is delayed, 
and breast feeding is therefore considered impossible. Dluski's 
figures * show how different the time of the " running-in " of the 
milk may be. She found that in 326 primiparae the running-in 
of the milk occurred as follows: 9 times after 24 to 48 hours, 115 
times after 48 to 72 hours, 159 times after 72 to 96 hours, 42 times 
after 96 to 120 hours, one time after 120 to 144 hours. The best 
method of hastening the appearance of the milk is by emptying 
the breasts as completely as possible. The best way to do this 
is by putting an older and stronger infant to the breast. The 
older infant not only sucks more strongly, but does not get as tired 
as the younger child, who often refuses to nurse after a few at- 
tempts, if the milk does not flow easily. If an older baby cannot 
be obtained, the mother's own infant may be used. 

The supply of milk is not infrequently insufficient while the 
mother is in bed, and nursing is on this account given up. It is not 
uncommon, however, to have the supply of milk increase and be 
amply sufficient after the mother is able to be out of bed and to 
take up her ordinary routine. 

It is sometimes thought that it is not worth while for a woman to 
nurse her baby unless she can nurse it for a considerable time. 
1 These de Paris, 1894. 
134 






NURSING A PHYSIOLOGICAL CONDITION 135 

This belief is, of course, entirely erroneous, because there is no time 
in a baby's life at which it is more important for it to have breast- 
milk than in the beginning. There is no time at which a baby's 
digestion is so easily disturbed and so hard to correct, if disturbed, 
as in the^early days and weeks of life. Every day or week that a 
baby gets breast-milk gives it a better start and makes it easier to 
put it on an artificial food later, if it is necessary. It is also some- 
times thought that it is hardly worth while to give a baby the 
breast, unless it can get all its food from the breast. Others believe 
that it is dangerous to mix human milk and artificial food. This 
belief is, of course, entirely erroneous. The artificial food cannot 
make the breast-milk harder of digestion, while the breast-milk 
clinically certainly seems to make the digestion of the artificial 
food easier. Every little bit of breast-milk helps the baby and 
makes it easier to feed it artificially. This may be due in part to the 
ferments which the breast-milk contains, but more probably is due 
to the fact that the baby is able to utilize the proteins of human 
milk to build tissues, when it is not able to utilize the proteins of the 
artificial food in the same way. 

Nursing is sometimes given up almost at once because of poor 
nipples or cracked nipples. Nursing should not be given up for 
these reasons until strenuous attempts have been made to draw out 
the nipples or to have the baby nurse with a nipple-shield. Cracked 
nipples will almost invariably heal if time and trouble enough are 
taken. 

In other cases nursing is not attempted because it is feared that 
the strain of nursing will be too great for the health of the mother. 
It is true that in some instances nursing does pull down the mother 
materially. It must not be forgotten, however, that nursing is a 
physiological and not a pathological condition, and that many 
women are better while nursing than at any other time. Even if it 
does pull a woman down, however, a mother should be willing to 
sacrifice herself to a certain extent in order to give the baby a good 
start. A few weeks or a few months of nursing will make all the 
difference to the baby in the future. It is often said that women 
are too nervous to nurse, that their milk will be bad on this account 
and that the baby will be disturbed and will not thrive. This is 
undoubtedly true in a certain number of instances. Other women, 
however, apparently as unsuitable for nursing, prove to be very 
good nurses. On this account, therefore, nursing should always be 
attempted, to be given up later if it is not successful. 

In general, women are altogether too prone to believe on in- 
sufficient grounds that they cannot nurse their babies. It is sad to 



136 FEEDING IN THE FIRST FEW DAYS 

say that they are often aided and abetted in this belief by physi- 
cians and nurses, who should know better. It is a hopeful fact, 
however, that the women among the well-to-do and educated 
classes are beginning to appreciate the importance of breast feeding 
and that many more of them are not only willing but anxious to 
nurse than were a few years ago. 

Feeding in the First Few Days of Life. — The baby should be 
put to the breast from six to twelve hours after birth, according 
to the condition of the mother and the strength of the baby. The 
object of putting the baby to the breast at this time is not to give 
the baby food, but to stimulate the breast to secretion. It is 
supposed that nursing also favors the involution of the uterus. 
There is, however, no positive proof that this is so. The baby 
should be put to the breast every six hours during the next twenty- 
four hours, and every four hours during the succeeding twenty- 
four hours. With the appearance of the milk, the interval may 
then be shortened. The average amount of colostrum obtained 
during the first twenty-four hours is from 4 to 6 c. c, and during 
the second twenty-four hours, 90 c. c. In the majority of cases the 
milk then comes in rapidly on the third and fourth days. In many 
instances, however, the milk does not come in until a day or two 
later than this. It is evident from the small amount of colostrum 
secreted during the first two or three days that the baby is not 
intended by nature to get much food during this time. Further 
proof of this fact is that the initial loss of weight is not prevented 
by feeding larger amounts of food from the beginning. It is well, 
however, to give the baby water freely in order to flush out the 
kidneys and make up for the water lost in other ways. One or two 
drachms should be given every two hours, more often if the baby 
wishes it and will take it. It is often advisable to give a solution 
of milk sugar and water at this time in order to favor the develop- 
ment of the normal bacterial flora. There is no proof, however, 
as to whether this is accomplished or not. Some believe that sugar 
at this time does harm, but there is no proof whether it does or not. 
It is probably, however, better on the whole to give a mixture of 
saccharin and water than sugar and water. 

Most babies begin to show signs of hunger after the first forty- 
eight hours. It must be remembered, however, that crying at this 
time does not necessarily mean hunger, because every new-born 
baby cries a certain amount. It is wiser to begin to give some food 
on the third day, if the supply of breast-milk is insufficient. It is 
not necessary to begin to feed them at this time, however, as 
experience has shown conclusively that it does the baby no harm 



FEEDING IN THE FIRST FEW DAYS 137 

to go four or five days without food. It is very important, when 
beginning to feed a new-born baby, not to give it too much food 
or too strong a food. There is no time in a baby's life in which it is 
so easy to disturb the digestion or at which it is so difficult to cor- 
rect the (Jisturbance, if it is once caused. If the baby is put to a 
breast whose secretion is already established, there is great danger 
that it will take too much food and be disturbed by it. The dura- 
tion of nursing must, therefore, be very short in the beginning. 
It is often wiser to give breast-milk diluted with water from a 
bottle for one or two days before putting the baby to the 
breast. It is probable, too, that the baby digests breast-milk 
better if it has had colostrum first. There is, however, no proof 
of this. 

If the baby has to be given an artificial food, it is very important 
not to give it too strong a mixture. It is absolutely wrong to say, 
as many physicians do, "Give it a little milk and water. It is not 
necessary to give it a mixture at this time, because it will be on the 
breast in a few days." The digestion is so easily disturbed at this 
time that there is no time at which it is more important to give a 
mixture suited to the baby. It is very important to begin with a 
weak mixture and to give it in small amounts. If this mixture is 
digested and the baby is still hungry, it is very easy to increase 
the strength and the amount of the food. If the baby is upset by 
too strong a food, it is a very difficult matter to correct the dis- 
turbance. The mixture should be low in fat and proteins, which 
are relatively hard to digest, and proportionally high in sugar, 
which is easy of digestion at this time. It is wise, also, to give a 
part of the proteins in the form of the whey proteins. A suitable 
mixture is fat 1%, milk sugar 5%, whey proteins 0.25%, casein 
0.25%. This may be quickly strengthened, perhaps in the first 
twenty-four hours, to fat 1.50%, sugar 6%, whey proteins 0.50%, 
casein 0.25%, and then in another twenty-four hours to fat 2%, 
sugar 6%, whey proteins 0.75% and casein 0.25%. Two drachms 
(10 c. c.) is enough at first. This can be quickly increased to one- 
half to one ounce (15 or 30 c. c). 

The colostrum is supposed to have a laxative action. Such an 
action, however, has not been proven. If the bowels have not 
moved well during birth or during the first twenty-four hours, it 
is wise to give a teaspoonful of castor oil in order to empty them, 
because of the possible danger of the absorption of the products of 
decomposition of retained meconium. It is probable that these 
products may cause convulsions and other severe nervous symp- 
toms, as well as fever and marked prostration. At any rate, such 



138 REGULARITY OF NURSING 

symptoms in the new-born are repeatedly relieved by the empty- 
ing of the intestinal tract. 1 

Intervals between Nursings. — There is much difference of opin- 
ion as to the proper intervals between nursings. This subject 
will be discussed later in detail in the chapter on artificial feeding. 

Regularity of Nursing. — Whatever intervals between nursings 
are adopted, the baby should be nursed regularly at these intervals. 
There is, of course, no doubt that many babies thrive in spite of 
being nursed at any and all times. On the average, however, babies 
do better when they are fed regularly. A baby quickly accommo- 
dates itself to being fed at regular intervals and soon learns to 
expect to be fed at these times and not at others. The mother, 
moreover, can arrange her time much better, if she knows when the 
baby is to be fed. It is very difficult for the modern woman, who 
has many other legitimate demands upon her time, to always be 
on hand at the nursing time. One bottle feeding a day makes it 
much easier for many women and enables them to nurse their 
babies when they would otherwise not be able to do so. An addi- 
tional advantage in one bottle feeding a day is that the baby 
becomes accustomed to the bottle and weaning is, therefore, much 
easier when it becomes necessary. It is especially pernicious to 
nurse the baby off and on all night. If this is done, the sleep of 
both mother and baby is disturbed and they suffer, the mother the 
more, from the loss of sleep. A baby should not be nursed more 
than once in the night, and this nursing should be stopped when 
the baby is a few weeks old. 

Waking to Nurse. — It is claimed by some authorities that a 
baby should not be waked to nurse, but should be allowed to sleep 
as long as it desires and nurse when it awakens, the only rule as to 
the length of the interval between nursings being that it shall not 
be less than 2 hours, so as to avoid feeding before the stomach is 
empty. There is no doubt that babies will thrive on this system of 
breast feeding, as they will on almost any scheme of breast feeding. 
This method is, however, not suited to the exigencies of modern 
life. Most women have to arrange their time systematically in 
order to fill all their engagements and cannot wait, therefore, on 
the baby's convenience. It is much wiser, on the whole, to wake 
the baby at the proper time. A normal baby that is fed regularly 
wakes in most instances at regular intervals and, in any case, will 
quickly go to sleep again after being nursed. 

Alternate Breasts. — If the supply of milk is sufficient, it is 
usually advisable to give the breasts alternately. By this method 
1 Morse: Amer. Journal of Diseases of Children, 1912, iv, 229. 



DURATION OF NURSING 139 

the breasts are more thoroughly emptied and the production of 
milk is encouraged. If both are given at the same time, they are 
not emptied and the production of milk is discouraged. There is, 
moreover ,*a tendency to reversion to the colostrum stage. If the 
supply of milk is insufficient, it is advisable to give both breasts at 
each feeding. The baby in this way gets a sufficient amount of 
food, the breasts are emptied and the production of milk is en- 
couraged. 

Duration of Single Nursing. — If the supply of milk is abundant 
and the baby well and vigorous, it will usually occupy about 
twenty minutes in nursing. Many normal babies will, however, 
take only ten or fifteen minutes in nursing. The time taken in 
nursing varies according to the sucking strength of the baby, the 
amount of milk in the breasts, and whether the breast is one which 
it is hard or easy to empty. It must be remembered in this connec- 
tion that the milk flows most freely at the beginning of a nursing, 
and that the amount obtained diminishes progressively with the 
duration of the nursing. The baby gets more than one-half of the 
meal in the first five minutes, more than one-quarter in the next 
five minutes, and but comparatively little after this. 1 If the baby 
nurses more than thirty minutes there is something wrong. The 
trouble may be that the supply of milk is insufficient, or that the 
baby is too feeble to nurse vigorously and continuously. The 
baby should not drop off to sleep while nursing. If it does, it 
means that the supply is insufficient and he gives up after getting 
a little, that he is not hungry and that the intervals should there- 
fore be lengthened, or that he is feeble or sick in some way. While 
the supply of milk is greatest at the beginning of the nursing, 
the strength of the milk increases progressively throughout the 
nursing, the total solids being greater at the end than at the begin- 
ning of a nursing. This difference is, however, not great enough 
to be of much practical importance. 

Amount Taken at Each Nursing. — The amount taken at a nurs- 
ing varies materially from nursing to nursing and bears no relation 
to the theoretical size of the stomach. A baby will take two 
ounces at one feeding, and six ounces at the next, and so on. A 
baby three weeks old will sometimes take as much as six ounces 
at a nursing, and one of two months as much as eight ounces at a 
nursing, and so on. The amount taken in twenty-four hours will, 
however, be approximately the same from day to day, increasing, 
of course, with the age of the baby. 2 Variations in the amount of 

1 Feer: Jahrbuch f. Kinderheilkunde, 1896, xlii, 195. 
* Peters: Archiv. f. Kinderheilkunde, 1902, xxxiii, 295. 



140 DIFFICULTY IN TECHNIQUE 

fat in the milk do, however, influence the total amount taken in 
twenty-four hours, less being taken when the percentage of fat 
is high. The explanation of the difference in the amount taken at 
different feedings is probably either that there is a variation in the 
supply of milk or that the baby is not as hungry at one time as at 
another. If it has taken a large amount at one feeding, it will 
naturally not take as much at the next and vice versa. The 
explanation of the fact that a baby can take an amount at a single 
nursing far in excess of its gastric capacity is that the milk passes 
directly into the duodenum, even during the act of nursing. 

Difficulty in Technique of Nursing. — If a baby does not nurse 
well, the trouble may be with the baby or with the mother. If the 
trouble is with the baby, it may be some deformity of the lips or 
mouth, nasal obstruction from adenoids or some other cause, which 
interferes with nursing, or weakness. Older babies that have been 
fed on the bottle are often unwilling to take the breast, because 
they are unaccustomed to it. Babies that are partly bottle and 
partly breast-fed will often refuse the breast because they have to 
work harder to get the milk from the breast than they do to get it 
from the bottle. 

Retracted or small nipples are the most common cause of 
difficulty in nursing on the part of the mother. In rare instances 
the nipples are too large. Cracked nipples also frequently interfere 
with satisfactory nursing. Many mothers do not know how to 
hold a baby to make it comfortable while nursing. Other mothers, 
through nervousness, disturb the baby and prevent it from taking 
hold and nursing satisfactorily. 

Treatment. — Deformities of the mouth and lips must be cor- 
rected. In general, it is not wise to operate on a hare-lip until the 
baby is at least six weeks old, or on a cleft-palate until it is at least 
six months old. The baby can be fed with breast-milk by means of 
a dropper, spoon, Breck feeder or tube in the meantime. Adenoids 
should be removed at once if they cause interference with nursing, 
no matter how young the baby may be. Feeble babies can be fed 
wholly or in part in the same ways as those with deformities of the 
mouth and lips. Babies that are unwilling to take the breast can 
usually be starved to it. Putting sugar on the nipples, pressing 
some of the milk into their mouths at the beginning of nursing, or 
the use of a nipple-shield will sometimes induce them to take hold. 
They will sometimes nurse in the dark or when blindfolded, when 
they will not otherwise. 

Care of the Nipples. — Something can be done during pregnancy 
to bring out retracted nipples by manipulation, careful application 






CARE OF NIPPLES 141 

of a breast-pump and sucking. The nipples should be carefully- 
washed aad cleaned during the latter days of pregnancy in order to 
remove the excess of epithelium and to clear the openings of the 
ducts. 

The nipples should be washed before and after each nursing with 
sterile water or with a saturated solution of boracic acid and 
thoroughly, but carefully, dried with a soft cloth or absorbent 
cotton. It is wise to protect them with a cloth moistened with 
albolene or boracic acid ointment between the nursings. If the 
nipples are tender they may be washed with a 50% solution of 
alcohol. If the nipples become cracked, the baby should not be 
allowed to nurse, except through a nipple-shield. If it does not 
throughly empty the breasts in this way, they should be emptied 
by massage or a breast-pump. Cleanliness and a simple ointment, 
like boracic acid ointment, are usually sufficient to heal them. 
In some instances, however, it is necessary to touch the cracks 
with a 1% or 2% solution of nitrate of silver. If the breasts are 
full or tender, they should be supported with a breast-binder and 
kept empty by massage and a breast-pump. It is safer, as a rule, 
to take the baby off of an inflamed breast and empty the breast 
by massage or with a breast-pump. If the milk contains no pus 
corpuscles there is probably, however, no risk to the baby, if the 
nursing is continued. 

Breast-Pumps and Nipple-Shields. — The so-called English 
breast-pump is very satisfactory. Caldwell * has recently de- 
scribed a simple and effective pump which the mother works by 
her own suction and by which the milk is collected in the nursing 
bottle in which it is to be given. The glass nipple-shields with a 
rubber nipple are the best. A baby will often nurse better from 
a shield if it is first filled with milk. 

Care of Baby's Mouth. — There is always danger of infection 
of the nipples and breasts from the baby's mouth, if it is not kept 
clean. The condition of the baby's mouth must, therefore, be 
watched. It is far more likely to become inflamed and infected, if 
it is washed than if it is left alone. The baby's mouth should, 
therefore, not be washed. A swallow of water after nursing is all 
that is necessary. 

Method of Nursing Baby. — The baby should be held lying on 
its side with its head a little elevated. It must be everywhere 
supported, so that it is relaxed and comfortable. The breast above 
the nipple must be pressed away from its nose, so that it can 
breathe freely. The mother and attendants must be quiet and 
1 Caldwell: Amer. Journ. Diseases of Children, 1915, ix, 391. 



142 ABNORMAL BREAST MILK 

composed. Otherwise the baby is disturbed and excited and will 
not nurse well. Vomiting after nursing can sometimes be pre- 
vented by having the mother lie down beside the baby while she 
nurses it. In other instances it is advisable to hold the baby up- 
right every few minutes during the nursing in order that it may 
get up the air which it swallows and which would otherwise cause 
vomiting. 

Not all Human Milk is Good Milk. — Everyone agrees that hu- 
man milk is the best food for infants. It is equally true, however, 
that not all human milk is good milk. Some milks will not agree 
with any baby. Other milks will agree with one baby and not with 
another. A milk which suits one baby will not suit another, and 
what suits the second baby will not suit the first baby. It is im- 
possible to determine from an analysis of a milk whether it will or 
will not agree with a given baby. This can only be told by expe- 
rience. Babies will often thrive on a milk which would, from its 
analysis, seem most unsuitable. The same baby will often thrive 
on different types of milk. While it is impossible to determine 
from an analysis of the milk whether it will or will not agree with 
a baby, it is, however, often possible, if a milk is not agreeing with 
a baby, to tell from the analysis why it does not. If a milk does 
not agree with a baby, the most common abnormality in the milk 
is an excessive amount of proteins. The next most common abnor- 
mality is an excess of fat. There is very seldom an excess of sugar. 

Types of Abnormal Milk. — Human milk may be unsuitable or 
abnormal in many ways. Three general types can be recognized: 

(1) All elements too high. 

(2) Fat and sugar low, proteins high. 

(3) Fat and sugar very low, proteins, very high. 

The first type is most often found in indolent women of the 
wealthy classes, who, being blessed with a good digestion, eat too 
much and too rich food. An example of such milk is the follow- 
ing: 

Fat 5.00% 

Sugar 7.50% 

Proteins 2.60% 

There is no difficulty in correcting this type of milk, provided 
the woman will eat properly and take exercise. It is, however, 
unfortunately rather hard to induce such women to change their 
habits. 



ABNORMAL BREAST MILK 143 

The second type is most often found in women of the poorer 
classes who are compelled to work hard and do not have sufficient 
food. It is, in fact, a starvation milk. A typical analysis of such a 
milk is 

Fat 1.75% 

Sugar 4.50% 

Proteins 2.50% 

This type of milk is also easily changed by giving sufficient food 
and diminishing the work. Unfortunately, it is, in this instance 
also, difficult to remedy the underlying social conditions. 

The third type is usually found in the highly-strung, over-edu- 
cated and highly-civilized women of the large cities, but may be 
found in neurotic women of any class or community. A charac- 
teristic analysis of this type of milk is 

Fat 1.00% 

Sugar 4.00% 

Proteins 3.75% 

It is practically impossible to modify this type of milk, because it 
is impossible to change the fundamental abnormality of the wo- 
man's nervous make-up. 

Analysis of Breast-Milk. — Too much reliance must not be 
placed on an analysis of the breast-milk, because the composition 
of milk varies in the same woman from day to day and from nurs- 
ing to nursing. It also differs at different periods of the same nurs- 
ing. An analysis is valueless, therefore, unless all the milk is taken 
from the breast, or at least samples from the beginning, the middle 
and the end of the nursing. The results of a single examination, 
even if the milk is properly taken, may also be misleading, because 
of the variation from day to day and nursing to nursing. Positive 
conclusions can be drawn only when the results of several examina- 
tions are similar. 

The Normal Breast-Fed Infant. — A baby that is thriving on 
the breast should gain from six to eight ounces a week during the 
first five months, and from four to six ounces a week during the 
rest of the first year. Smaller but steady gains are, however, not 
necessarily abnormal. It should double its birth weight in the 
first five months, and treble it at the end of the first year, or a 
little later. It should have from two to four smooth, orange-yellow 
stools of the consistency of thick pea-soup daily during the first few 
months, and from one to three similar stools of somewhat greater 



144 THE ABNORMAL BREAST-FED INFANT 

consistency during the rest of the first year. It should not vomit 
unless it is disturbed or shaken up soon after a feeding. It should 
not cry unless hungry or when uncomfortable from wet diapers, 
wrinkles in its clothing, and so on. Its flesh should be hard and 
firm, its lips, cheeks and nails pink. It should sleep from twenty to 
twenty-two hours out of the twenty-four during the first two 
months, and about sixteen hours a day during the latter half of 
the year. It should be happy when awake, active when given the 
opportunity. 

Theoretically the normal baby should gain regularly every day 
and should never lose. Practically this never happens. The baby 
gains one day, remains stationary another day and loses on a third, 
there being, however, a steady gain from week to week. Very 
few babies, however, get through the year without, for some reason, 
which may or may not be apparent, failing to gain or losing for one 
or more weeks. 

Many babies that are gaining regularly and apparently thriving 
in every way on the breast have abnormal stools. The attempt 
should be made to correct these stools by modification of the milk 
through regulation of the mother's diet and life. The baby should 
not be taken off the breast, however, even if the attempt is un- 
successful. A baby that is gaining and thriving in other ways 
should never be weaned simply because the stools are abnormal, 
no matter how abnormal they may be. Many a baby has been in- 
jured, and not a few killed, by being taken off the breast on this 
account. It must never be forgotten that stools which in the 
artificially-fed baby mean serious disturbance of the digestion and 
demand prompt modification of the food can be practically dis- 
regarded in the breast-fed, provided the babies are thriving in 
other respects. 

The Abnormal Breast-Fed Infant. — When a breast-fed baby, 
which is not gaining properly, has one or more normal stools daily 
and is not vomiting, it is almost certain that the failure to gain is 
not due to any defect in the quantity or quality of the milk. The 
source of the trouble must be sought elsewhere. It will then be 
found that the baby is being improperly handled in some way or 
that it has some disease. It may be that it is excited too much, 
that it does not get enough sleep, that it does not get enough fresh 
air, or that it is not kept warm enough. Hidden tuberculosis, 
pyelitis and an insufficient supply of air as the result of adenoids 
are frequent causes of failure to gain. 

Failure to gain in weight may or may not be associated with 
symptoms of disturbance of the digestion. 



THE ABNORMAL BREAST-FED INFANT 145 

If there are no symptoms of disturbance of the digestion and 
the baby is constipated, as it usually is, the food is deficient in 
quantity, quality, or both. If the supply of food is sufficient to 
allay the pangs of hunger, the baby will not appear hungry, even 
if the food is entirely inadequate to enable it to gain in weight. 

The only way to determine how much milk a baby is getting 
from the breast is to weigh it before and after each nursing for 
twenty-four hours. The difference in weight shows the amount of 
milk taken, as an ounce of milk weighs practically one ounce avoir- 
dupois. It is not sufficient to weigh the baby before and after one 
or two nursings, because of the difference in the amount of milk 
taken at different nursings. The total amount taken in twenty- 
four hours must always be determined. It is, of course, unneces- 
sary to undress the baby in order to weigh it. If the baby is restless 
and it is hard to weigh it accurately, the same result can be ob- 
tained by weighing the mother before and after nursing. What she 
loses represents, of course, the amount of milk taken by the baby. 

Other methods of estimating the amount of milk are very unre- 
liable. It is impossible to tell the amount of milk from the size of 
the breasts. Many large breasts secrete but little milk, while 
other small breasts secrete a considerable amount of milk. It is 
impossible, also, to determine the amount of milk by attempting to 
express it or by taking it out with a breast-pump, because a baby 
will often get a large amount of milk from the breast when but lit- 
tle or nothing can be obtained by expression or with a pump. Evi- 
dence of considerable importance in favor of an insufficient supply 
of milk is when a baby wakes up hungry some time before every 
feeding. Other suggestive evidence is when a baby drops the 
nipple during the feeding and cries with anger, or when it grabs the 
nipple and shakes it as a puppy does a root. 

The quality of the milk can only be determined by chemical 
analysis. Great care must be exercised, however, in the interpre- 
tation of the findings of such an analysis, as has already been ex- 
plained. Under these conditions the milk is usually weak in all its 
constituents, or the percentage of fat is very low, while the other 
elements are approximately normal. 

When there are symptoms of a disturbance of the digestion, 
there is either an excessive amount of milk or the quality of the 
milk is abnormal. When there is an excessive amount of milk the 
baby usually vomits, especially soon after nursing, and has too 
many stools, which, in most instances, are in some way abnormal. 
The quantity of the milk can only be positively determined, how- 
ever, by weighing the baby or the mother before and after each 



146 MODIFICATION OF BREAST MILK 

nursing for at least twenty-four hours. Abnormalities in the com- 
position of the milk are shown by colic, vomiting and abnormal 
stools. The abnormality is usually an excess of fat or proteins, 
more often of proteins, rarely of sugar. An excess of fat is shown 
in most instances by the presence of small, soft curds in the stools, 
the typical soap stool being unusual in the breast-fed baby. When 
there is an excess of proteins, the stools are likely to be watery, to be 
somewhat brownish in color and to contain mucus. They are often 
greenish and frequently contain mucus when the milk is abnormal 
in any way, but the typical, green, fermented, irritating stool of an 
excessive amount of sugar is seldom seen. The only way in which 
the error in the composition of the milk can be accurately deter- 
mined, however, is by chemical analysis of the milk, due regard 
being paid to the possibilities of mistakes in drawing conclusions 
from such analyses. 

Modification of Breast-Milk. — The secretion of breast-milk 
and the various factors which influence it have been discussed in a 
previous chapter. It will perhaps be well, nevertheless, to review 
the subject from the clinical standpoint. In the first place, lacta- 
tion is, or should be, a physiological, not a pathological process. 
A nursing woman is in a normal, not an abnormal, condition. 
She should, therefore, lead the same sort of life when she is nursing 
that she does when she is not nursing, provided her manner of 
living is a normal one. In view of the fact that there is a certain 
amount of additional strain in nursing, she should be careful not to 
overdo or to get overfatigued. Her diet should be that to which 
she is accustomed when she is not nursing. There is no reason why 
she should not eat anything which does not disturb her digestion, 
but should, as when not nursing, avoid articles of food which dis- 
agree with her. There is very little in the old theory that a nurs- 
ing woman should avoid certain fruits and vegetables because they 
will disturb the baby's digestion. It is true that sometimes when a 
given woman eats a given thing the baby will be disturbed. It is 
impossible to tell in advance, however, what this thing will be. 
Moreover, the thing which causes disturbance in one instance will 
not cause disturbance in the next, while something else will. A 
nursing woman should, therefore, eat a general diet, avoiding 
articles of food which disturb her digestion. If her baby is upset, 
she should try to remember what unusual article of food she has 
eaten. If the baby is upset when she eats it again, she should 
avoid it in the future. 

Modification of Quantity of Breast-Milk. — In the first place, 
it must be remembered that Nature tends to accommodate the 



MODIFICATION OF BREAST MILK 147 

supply of breast-milk to the demand. If but little is taken, little 
will be produced. If much is taken, much will be produced. The 
best stimulant to the secretion of milk is the thorough emptying of 
the breast. There is nothing else which tends to increase the 
quantity so much. The next best stimulants to the secretion of 
milk are a liberal, general diet and a normal life. Increasing the 
quantity of liquid in the diet increases the quantity of milk to a 
certain extent. It is useless, however, for a woman to take more 
than a quart of extra liquid daily. More than this either disturbs 
her digestion or makes her grow fat. This extra liquid should 
not be too rich. It is given chiefly for its action as a liquid, not as a 
food. If it is given in the form of chocolate, eggnogs, and things of 
like nature, it takes away the appetite for solid food, and the 
total ingestion of food is not only not increased but often dimin- 
ished. Milk and cocoa shells are probably the best drinks. Gruels 
seem to have a certain action as galactagogues. So do malt liquors 
in some instances. It is better not to use them as a rule, however, 
because they are likely to disturb the digestion and fatten the 
mother. There is no danger to the baby from their alcoholic con- 
tent. There are no drugs which, whether taken internally or applied 
externally, can increase the flow of milk to any appreciable extent. 

It is seldom necessary to diminish the quantity of milk. Diminu- 
tion in the amount of food and liquid ingested will usually speedily 
diminish the supply of milk. Moreover, if the breasts are not 
thoroughly emptied, Nature will quickly reduce the supply. 
External applications are usually not efficacious and always in- 
advisable. The bowels may be opened freely, if necessary, to re- 
duce the amount of milk temporarily. 

Modification of Quality of Breast-Milk. — When the total solids 
of the milk are all high, as the result of overeating and lack of 
exercise, they can be reduced by regulation of the diet and exercise. 
When they are low, as the result of starvation and malnutrition, 
they can be increased by proper food and care. They can also be 
influenced to a certain extent by varying the intervals between 
nursings. Lengthening the intervals diminishes the total solids; 
shortening the intervals increases them. 

It has been taught for many years that the amount of fat in 
the milk varies directly with the amount of protein in the food. 
This teaching is, however, erroneous, the only way in which the 
protein in the food can increase the fat in the milk being by im- 
proving the general condition. The amount of fat in the food has 
but little influence on the amount of fat in the milk. If the mother 
is underfed, an increase in the fat in the food will temporarily re- 



148 MODIFICATION OF BREAST MILK 

suit in an increase in the fat in the milk. If she is not underfed, an 
increase in the fat in the food does not increase the fat in the milk. 
An excessive amount of fat in the milk is most often due to an 
excessive amount of food in general rather than to an excess of 
any one element and can be diminished best by cutting down the 
food as a whole. An insufficient amount of fat in the milk is 
usually due to malnutrition. It can be increased by building up 
the general condition by increasing the supply of food and regula- 
tion of the life. An increase in the amount of fat in the food will 
also sometimes temporarily cause an increase in the percentage 
of fat in the milk. When a breast-milk is low in fat, but other- 
wise of good quality, it is easy to make up for the deficiency of 
fat by giving the baby cream with the nursings. Enough cream 
should be given to bring the percentage of fat to the proper level. 
For example, if a baby is taking four ounces of breast-milk, con- 
taining 1% of fat, the addition of one-half ounce of gravity cream 
will raise the percentage of fat to three. The cream may be given 
before or after the nursing, but is best given in the middle of the 
nursing. A very good way to give it is from a dropper introduced 
into the mouth beside the nipple while the baby is nursing. 

The percentage of the sugar in the milk cannot be directly 
influenced in any way. It tends to vary directly with the general 
condition of the mother. 

The percentage of protein in the milk can be influenced to a 
certain extent, according to Hoobler, by changes in the diet. 
The amount of protein in the milk can be increased by increasing 
the proportion of protein in the food in relation to that of the 
combined fat and carbohydrate and by increasing the proportion 
of animal to vegetable protein. It can be diminished by giving 
a diet containing a relatively large amount of fat and carbohy- 
drate in proportion to the protein and by giving most of the pro- 
tein in the form of vegetable protein. The protein of milk is the 
most efficient form of protein for the production of protein in 
human milk. The most common cause of an excessive amount of 
protein is nervousness. If the mother's nervous condition can be 
quieted, the percentage of protein will diminish. The amount 
of protein can also be diminished by exercise, but if the exercise 
is excessive and causes fatigue, the protein will be increased. In 
many cases, therefore, when the woman is overtired, the protein 
can be diminished by rest. 

Mixed Feeding. — When a woman does not have sufficient milk 
to satisfy her baby, the baby should not be weaned, but should 
be given an artificial food in addition to the breast-milk. If the 



MIXED FEEDING 149 

supply of milk is almost sufficient, the baby may be given the 
artificial food entirely at one or at two feedings and the breast at 
the others. It is hardly ever advisable to omit more than two 
nursings, because the supply of milk is likely to diminish still 
further from lack of stimulation of the breasts, if more than this 
number of feedings are omitted. If there is much deficiency in 
the supply, the breast should be given at each feeding, followed 
by an artificial food. The amount of artificial food to be given 
depends, of course, on the amount of breast-milk. This is best 
determined by weighing the baby or mother before and after nurs- 
ing and giving enough artificial food to make up the proper amount 
for a feeding. It is usually not necessary to weigh the baby be- 
fore and after every feeding, once the average amount obtained 
from the breast has been ascertained. 

No attempt should be made, in deciding on the composition of 
the artificial food, to imitate the composition of the breast-milk. 
The fact that the baby can digest human milk of a given composi- 
tion does not indicate at all that it can digest a cow's milk mixture 
of the same composition, because, although the percentages of the 
components of the two foods may be the same, the foods are 
different. One is human milk; the other is cow's milk, in spite of 
the fact that it is modified. The composition of the artificial food 
should be decided on general principles, based on the age and 
apparent digestive capacity of the infant. An analysis of the 
breast-milk is, however, sometimes of assistance in determining 
what shall be the composition of the artificial food, because in some 
instances, in which there is a deficiency of some element in the 
breast-milk, it can be corrected by an increase in the amount of 
this element in the artificial food. 

Weaning. — A baby should not be taken off the breast unless 
there is a good reason for doing so. A baby should not be weaned 
during the early weeks of life, on the ground that the milk is 
unsuitable, simply because the baby has the colic and abnormal 
stools. It is wiser to wait until the mother is out of bed and has 
resumed her usual mode of life before deciding that the milk will 
not agree, because in many instances the symptoms of indigestion 
cease and the baby begins to thrive as soon as the mother gets back 
to her normal routine. It is important, on the other hand, not to 
wait too long and allow the digestion to get throughly upset be- 
fore weaning. A baby should not be weaned hastily on account 
of cracked nipples. These can almost always be cured and the 
nursing continued. 

A baby should not be weaned because of the appearance of 



150 WEANING 

menstruation. As a matter of fact, more women menstruate dur- 
ing the period of lactation than do not. Moreover, the changes 
which take place in the chemical composition of the milk during 
menstruation are no greater than the variations which are likely 
to occur at any time during lactation. In most cases the baby 
shows no evidences of disturbance of digestion during the men- 
struation; in some, the baby ceases to gain during this time and 
has the colic or undigested stools. A very few are seriously dis- 
turbed. They should not be weaned, however, but should be 
given an artificial food while the menstruation lasts and put back 
on the breast as soon as it is over. 

Pregnancy is an indication for weaning. It is impossible for a 
woman to nourish three individuals, herself, a baby on the breast 
and another in utero. Someone is sure to suffer, most often the 
baby on the breast. 

Acute disease in the mother is often an indication for weaning. 
If the disease is contagious, it is usually advisable to wean the 
baby to protect it from contagion. The younger the baby, the 
less likely it is, however, to contract the disease, because babies 
are born with a natural immunity to many of the contagious dis- 
eases. If it is not contagious, the question of nursing must be 
decided on the circumstances in the individual case. If the dis- 
ease is a mild one, the baby may be kept on the breast or taken 
off temporarily while the secretion of the breast is kept up in other 
ways. If the disease is a severe one, the milk will probably dry 
up wholly or in part and become poor in quality, so that the baby 
will have to be taken off the breast anyway, even if the condition 
of the mother warranted the continuance of the nursing, which it 
usually does not. 

The development of a chronic disease in the mother is usually an 
indication for weaning. In other instances, although the baby is 
thriving, the strain of nursing enfeebles and debilitates the mother. 
The decision as to weaning in such cases must be made on the 
merits of the individual case, bearing in mind the fact that it is a 
mother's duty to nurse her baby as long as she can do it without 
serious detriment to herself. The older a baby is, the less depend- 
ent it is upon breast-milk. Weaning is justifiable, therefore, for 
slighter disturbances of the mother's health after the first few 
months than it would be before. 

It is, unfortunately, not often necessary to decide when to wean, 
because the milk gives out and the baby has to be fed artificially. 
Under these circumstances the milk usually diminishes slowly and 
the baby is gradually weaned without difficulty. 



WEANING 151 

If the supply of milk continues sufficient in amount, it is ad- 
visable to wean the baby when it is between ten and twelve months 
old. Babies rarely thrive on the breast alone more than a year, and 
seldom as long as this. They become anaemic and, while fat, 
usually get flabby. The cause of the anaemia is that breast-milk 
does not contain sufficient iron to cover the need for this substance 
and the iron stored in the liver at birth is usually used up before 
this time. If a baby is doing fairly well on the breast, it is in most 
instances advisable to continue nursing through the summer 
months, even if the baby is a year or more old in the autumn, be- 
cause babies on the breast are much less liable to disturbances and 
infections of the digestive tract than those that are artificially fed. 
A baby should never be weaned in the spring to avoid weaning in 
the summer. The old idea that it is very dangerous to wean babies 
in the summer originated in the fact that babies weaned in the 
summer got contaminated milk and were therefore made sick, 
while those weaned in the spring got uncontaminated milk and 
were therefore less often upset. The truth of the matter is that the 
older a baby is, the better able it is to take an artificial food, pro- 
vided that food is suitable and clean. 

Babies should always be weaned slowly, if possible. It is much 
easier for the mother and the baby is much less likely to be made 
ill by the change to artificial food. If it is made ill, it can usually 
be put back on the breast again without difficulty. If it is weaned 
suddenly and the milk is gone, as it usually is in a few days, the 
baby cannot get anything from the breast at first, although it may 
later. It is often possible to bring back the milk, by putting the 
baby to the breast regularly, even several weeks after breast feed- 
ing has been omitted. Weaning is much easier if the baby has been 
in the habit of taking one bottle a day from the beginning of nursing. 
This custom is advantageous for many reasons. It gives the mother 
far more freedom, enables her to nurse longer, gets the baby 
accustomed to taking the bottle as well as the breast and habit- 
uates it to the digestion of an artificial food, as well as showing 
what sort of artificial food it can take. If the baby has had one or 
more bottle feedings daily, there is usually no trouble in weaning it 
gradually and neither mother nor child is disturbed. If it is more 
than a few months old and not accustomed to the bottle, it is 
much harder to wean it gradually, because the baby will refuse all 
food except the breast-milk and cannot be starved into taking it. 
When the baby will not take food in any way except from the 
breast, and when it has to be weaned because of the mother's 
illness or for some other emergency, the breast feeding has to be 



152 WEANING 

stopped suddenly. It is best to separate the baby from its mother, 
but in any case some other person must give it its food. It cannot 
be expected to take it from its mother, whom it has been in the 
habit of nursing. A little baby should be given the bottle. An 
older baby should be fed from a glass or with a spoon. If it refuses 
to take food after reasonable coaxing and urging, it should be 
allowed to go hungry until the next feeding. Most babies will 
yield to the pangs of hunger after from twenty-four to forty-eight 
hours and take what is offered to them. Occasionally, however, a 
baby will not give in and it has to be forced to take food or fed with 
a tube to save it from starvation. Such babies should always be 
closely supervised because of the possibility of the development of 
acidosis. 

When a baby has been taking one feeding of artificial food a day, 
there is no difficulty in deciding what food to give it. The same 
food is continued, the number of feedings being merely increased. 
When a baby that has been exclusively breast-fed can be weaned 
slowly, it is safe to give it a fairly strong food. It is usually possible 
when it is nine months or more old, to wean it directly on to a 
dilution of whole milk. It is also usually advisable to add starch to 
the mixture, because a baby of this age is perfectly capable of 
digesting starch and because, outside of milk, starchy foods will 
form the principal part of its diet for the next few months. A 
mixture of three parts of whole milk and one part of a 3% barley 
water, giving fat 3%, sugar 3.36%, proteins 2.62% and starch 
0.75%, is a reasonable one for a baby of this age. When a baby is 
weaned suddenly, it should always be given a weaker mixture than 
a baby of the given age would naturally take, in order to avoid, if 
possible, disturbance of the digestion from the artificial food. It is 
easy to strengthen the food if it agrees, difficult to correct dis- 
turbances of the digestion caused by too strong a food. The 
strength of the mixture must depend, largely, of course, on the 
age of the baby. Whey mixtures are the most suitable for young 
babies, mixtures with cereal diluents for older babies. 



CHAPTER XII 
WET-NURSES 

There can be no question that the most suitable food for an 
infant that is so unfortunate as not to be nursed by its mother is 
the milk of another woman. In fact, the milk of some other woman 
is not infrequently better for a baby than that of its own mother, 
when she is nervous and feeble while the stranger is placid and 
strong. In former days so little was known about the artificial 
feeding of infants that unless a wet-nurse was obtained the pros- 
pects of survival of a baby deprived of its mother's milk were not 
over-bright. At present, however, on account of the great ad- 
vances which have been made in artificial feeding, a normal baby 
can be expected to do well, if artificially fed, provided that its 
feeding is directed by someone familiar with the subject. Wet- 
nurses are not, therefore, the necessity for well babies which they 
were in the past. The situation is different, however, in the case of 
premature, feeble and ill babies. Many of these can be saved by 
human milk who, without it, would surely die. Many others, who 
eventually pull through on artificial feeding after months of illness, 
can be immediately restored to health by human milk. A very 
good rule to follow is not only never to allow a baby to die, but 
never to allow a baby to get into a condition in which it may die of 
disturbances of nutrition or of diseases of the digestive tract with- 
out getting it a wet-nurse, provided a wet-nurse can be procured. 

Wet-nurses are often not an unmixed blessing in a family. They 
realize their own importance and not infrequently take advantage 
of it, causing much disturbance in the household. In general, 
however, they are much like other people, good, bad and indiffer- 
ent. Like other people, too, how they conduct themselves depends 
very largely on how they are treated. Even if they do cause 
trouble, however, a family should be willing to put up with con- 
siderable domestic disquiet for the sake of saving their baby's 
life. Household worries are not to be compared with the anxiety 
attendant on the illness of a baby. 

Every mother dislikes to have another woman nurse her baby. 
She should, however, in the first place, appreciate the fact that if 
she was fulfilling her duty to her baby, a wet-nurse would not be 

153 



154 WET-NURSES 

necessary, and in the second place, should be not only willing, but 
glad, to sacrifice her own feelings for the good of her infant. There 
is, of course, no possibility of the transference of mental, moral or 
physical characteristics from the nurse to the baby. If there was, 
it would be far better for many babies to have wet-nurses than to 
nurse their own mothers. It makes no difference to the baby what 
is the color, race, creed, disposition or moral character of the nurse, 
provided her milk is of good quality and sufficient in quantity. 

It is sometimes said that it is wrong to employ wet-nurses, 
because it is immoral to deprive one baby of its natural nourish- 
ment and give it to another. This objection is not well-founded, 
because women do not go out as wet-nurses for pleasure, but 
because they are compelled to support themselves and their babies. 
The wages which they earn as wet-nurses are higher than they can 
get in any other way and, if they board their babies out, they are 
enabled to board them in better places and to save money for the 
future. It is always advisable, however, for a nurse to have her 
own baby with her. Her baby can then be properly cared for, she 
becomes fond of it and is more likely to care for it in the future, 
and, if she has made a mistake, is more likely to live straight in the 
future for the sake of her baby. It is often an advantage to the 
foster baby for the nurse to have her own baby with her, because 
she is happier and more contented. In many instances, moreover, 
the foster baby is, at any rate at first, not strong enough to empty 
the breasts and to keep up the supply of milk. Under these cir- 
cumstances, the nurse's baby can empty the breasts and keep them 
going. Many women are able, moreover, to nurse both babies. 

Wet-nurses are often objected to on the ground of expense. This 
must vary, of course, with the locality and the circumstances in the 
individual case. It is safe to say, however, that the cost of the wet- 
nurse, including her board and that of her baby, will be less than 
that of an artificial food and the doctor's bills, which will be saved. 

Qualifications of a Wet-Nurse. — A wet-nurse should be healthy 
and free from syphilis, tuberculosis and other chronic diseases. 
No woman should be accepted as a wet-nurse without a complete 
physical examination by a competent physician. Syphilis cannot 
be positively excluded, even if neither mother nor child show any 
evidences of it. A Wasserman test should be done, therefore, if it 
is practicable. Equal care should be taken to determine, however, 
that the baby that she is to nurse is not syphilitic. It is just as bad 
to have the baby infect the wet-nurse with syphilis as it is to have 
the wet-nurse infect the baby. It is impossible to determine from 
the general appearance of a woman or from the size, shape or feel- 






WET-NURSES 155 

ing of her breasts whether she has or has not a good supply of milk. 
Many small, thin women have much milk, and many large, 
vigorous-looking women but little milk. Small breasts often 
secrete much milk, and large breasts but little milk. The milk is 
secreted by gland tissue, not by fat, and it is impossible to tell by 
the appearance or feeling of a breast what is fat and what is gland 
tissue. The ease with which milk can be expressed from the breast 
is also unreliable as a guide, because a baby can often obtain much 
milk from a breast from which but little milk can be expressed, 
while in other instances where there is but little milk, it can all be 
easily expressed. The only way in which the quantity of milk 
which the breast is secreting can be positively determined is by 
weighing the wet-nurse's own baby before and after each nursing 
for at least twenty-four hours. Next to this is the appearance of 
her baby. If it is thriving, it is evident that it gets a sufficient 
supply of milk and that this milk is of good quality. It is useless 
to examine the milk to determine whether it will be suitable for 
another baby or not, partly because of the variation in the milk 
from day to day and nursing to nursing, and partly because it is 
impossible to know in advance whether or not a given milk will 
agree with a given baby. 

The composition of breast-milk being the same from the end of 
the colostrum stage until nearly the end of lactation, it is not 
necessary that the foster baby and the nurse's baby shall be of the 
same age. It is not advisable, however, if prolonged nursing is 
anticipated, to take a woman as a wet-nurse who is approaching 
the end of the period of lactation. The only objection, however, 
is that her milk is likely to give out and that it will be necessary to 
procure another nurse. It must be remembered that if a feeble or a 
young baby is put to the breast of a woman with an abundance of 
milk, it cannot empty the breast and that, the stimulation to 
secretion being removed, the supply of milk will diminish and 
perhaps cease. Many a good nurse has been spoiled in this way 
and discharged as having no milk when the trouble was not with 
her but with the baby. It is a great advantage under these condi- 
tions for the nurse to have her own baby with her to empty the 
breasts. A small or young baby may be upset, also, by taking 
too much food from a full breast which has been nursed by an 
older child. This mishap can be prevented by weighing the baby 
before and after nursing. 

Management of Wet-Nurses. — A wet nurse should be given the 
sort of food to which she is accustomed, and should be given the 
sort of work to do which she has been in the habit of doing. If a 



156 WET-NURSES 

woman that has been in the habit of doing hard, manual labor and 
eating plain, coarse food is given rich food and allowed to sit about, 
she is likely to become ill and the equilibrium of her milk is almost 
certain to be disturbed. On the other hand, a woman that has 
been in the habit of leading a sedentary life, as a seamstress, for 
example, and eating delicate food, cannot do hard work and eat 
coarse food without some disturbance of her milk resulting. Many 
a good wet-nurse has been spoiled by lack of attention to these 
details. 

Methods of Procuring Wet-Nurses. — It is almost always pos- 
sible to find a wet-nurse if the quest is undertaken with sufficient 
energy. They are most readily obtained at maternity homes and 
hospitals. In other instances they may be obtained through 
physicians and district nurses, or by advertising for them. There 
has been in Boston, for several years, a Directory for Wet-Nurses, 
where a considerable proportion of the women who wish to be 
nurses go. They are examined physically and the Wasserman test 
is done on them. The quantity and quality of their milk are also 
determined. They are not sent out unless they are healthy and 
their milk satisfactory. When they are through with one case they 
return to the Directory and wait for another. A reasonable fee is 
charged by the Directory for providing them. 1 This is the best 
solution of the problem in that it makes it easy to find a wet-nurse, 
assures the health of the wet-nurse, and is available for people liv- 
ing not only in the vinicity but also at a distance. 

In many instances in which it is impossible for some reason to 
get a wet-nurse, breast-milk can be expressed from the breasts of 
one or several women and fed to the baby in a bottle. It makes no 
difference in the result whether the baby gets it directly from the 
breast or indirectly from the bottle. It is breast-milk just the 
same. The Boston Floating Hospital has, for several seasons, 
obtained considerable amounts of breast-milk in this way through 
the cooperation of several of the philanthropic and nurses' soci- 
eties in Boston, and used it with good result. 2 

Breast-milk may also be preserved by freezing and used when 
desired. Schlossmann always has a number of wet-nurses at his 
hospital and during the winter months, when he does not use so 
much breast-milk as at other times, he saves the excess and freezes 
it, holding it in a refrigerator until the summer months, at which 
time the demand is greater. He then takes it as needed and 
claims very good results with it. 

1 Talbot: Journal A. M. A., 1911, vol. lvi, p. 1715. 

2 Talbot: Boston Medical and Surgical Journal, 1911, cbriv, 290. 



SECTION III 
ARTIFICIAL FEEDING 

CHAPTER XIII 
COW'S MILK. CHEMISTRY AND BIOLOGY 

COLOSTKUM 

The colostrum of cow's milk is never used in infant feeding, 
except by accident, and, for that reason, will only be treated in 
brief. It is probable that the explanation of the presence of the 
colostrum bodies in cow's milk is the same as in human milk. 

Colostrum is a thick, shiny, yellowish or reddish fluid with a 
taste more salty than that of normal milk. 1 It is sometimes alka- 
line, but more often acid. The specific gravity ranges between 
1.046 and 1.080, and it is richer in solids than ordinary milk. The 
appearance and composition gradually change during the course 
of a week, at the end of which it becomes milk suitable for use. 

The following analysis given by Engling 2 shows the way in which 
the milk changes: 

TABLE 29 







Number of hours after calving 


Normal 
Milk 




Imme- 
diately 


10 


24 


48 


72 




Water 


73.17 


78.77 


80.63 


85.81 


86.64 


87.75 


Casein 


2.65 


4.28 


4.50 


3.25 


3.33 


3.00 


Albumin 
Globulin 


16.56 


9.32 


6.25 


2.31 


1.03 


0.50 


Extractives . . . 


3.54 


4.66 


4.75 


4.21 


4.08 


3.40 


Sugar 


3.00 


1.42 


2.85 


3.46 


4.10 


4.60 


Ash 


1.18 


1.55 


1.02 


0.96 


0.82 


0.75 







1 Jensen's Milk Hygiene (Pearson) : Phil, and London, 1907, p. 12. 

2 Taken from Jensen's Milk Hygiene (Pearson), Phil, and London, 1907, p. 30. 

157 



158 COW'S MILK. CHEMISTRY AND BIOLOGY 

The fat in colostrum has a somewhat higher melting point and is 
poorer in volatile fatty acids than the fat in ordinary milk. 1 

The proteins in the colostrum of cows resemble those in human 
milk in that the greater part of them will coagulate. 

cow's milk 2 

Appearance, Smell, Taste. — When milk is perfectly fresh, it is 
a white, or yellowish white, opaque fluid. It separates into two 
distinct layers, when it is allowed to stand undisturbed for some 
time. The upper and lighter layer, which consists largely of 
globules of fat and is called " cream," is yellower than the lower 
layer, which is white or bluish white and is known as "skimmed 
milk." When it is pure and fresh, milk has either a faint, insipid 
odor, or no odor at all, and a mild, faintly sweetish taste. 

Microscopic Appearance. — Like human milk, it contains many 
minute fat droplets suspended in the form of an emulsion. There 
are more ultramicroscopic particles than in human milk, be- 
cause it contains a larger amount of casein. 

Specific Gravity. — The specific gravity of the fat in cow's milk 
is different in different breeds of cattle and varies between 0.922 
and 0.937. 3 The specific gravity of whole milk varies between 
1.028 and 1.035 at 15° C. (60° F.). Jenson gives 1.027 to 
1.040. 

Reaction. — The reaction depends either on the carbon dioxid 
and acid phosphates 4 or on the mono- and diphosphates in the 
milk. 5 Cow's milk is described as amphoteric to litmus paper. On 
standing exposed to the air, it becomes acid. The degree of the 
acidity and the rapidity of the change depend on the kind and on 
the amount of bacterial activity by which milk sugar is split up 
into lactic acid. Fresh milk has been studied with different in- 
dicators and it has been found that 100 c. c. of milk has the same 
alkaline reaction toward blue litmus as 41 c. c. of N/10 caustic 
soda, and the same acid reaction toward phenolphthalein as 19.5 

1 Nilson: Maly's Jahrsber. 21. 

2 The following publications are drawn from freely in the ensuing section: 
Kastle and Roberts: The Chemistry of Milk Hygiene, Lab. Bulletin No. 56, 
Washington, 1909, p. 315; Jensen's Milk Hygiene, Phila. and London, 1907, 
and Voltz: Chemie der Kuhmilch in Oppenheimer Handbuch der Biochemie 
des Menschen und der Thiere, vol. iii, first half, Jena, 1910, 386; Hammarsten 
A Textbook of Phys. Chemistry, N. Y., 1912; Koeppe and Raudnitz in Som- 
merfeld's Handbuch der Milchkunde, Wiesbaden, 1909. 

'Heischmann: Lehrbuch der Milch virtschaft., Heinsiws Machf., Bremen. 
4 Leach: Food Inspection and Analyses, N. Y., 1907, ii. 
6 Richmond: Analyst, 1900, xxv, 121. 



COW'S MILK. CHEMISTRY AND BIOLOGY 159 

c. c. of N/10 sulphuric acid. 1 Bahrdt and Edelstein 2 did not find 
any volatile fatty acids in either fresh cow's or human milk. When 
milk is allowed to stand, the volatile fatty acids appear. The 
average hydrogen ion concentration of cow's milk is 2.6X10~ 73 
Cow's milk conducts electric currents because it contains dis- 
solved salts. Fifty-eight per cent of the molecules of the mineral 
salts in cow's milk and 26% in human milk are dissociated. 4 

Quantity. — Since the quantity of milk is of moment only to the 
milk producer, it will not be considered here. 

The Coagulation of Cow's Milk. — By the coagulation of cow's 
milk is meant all the processes concerned in the precipitation 
of casein. 

(a) Effect of Acids on Coagulation of Milk. — Perfectly fresh 
amphoteric milk does not coagulate on boiling. A pellicle, con- 
sisting of coagulated casein and lime salts, is formed on the surface. 
This re-forms rapidly after being removed. 5 Fresh milk does not 
coagulate on boiling, even after a current of carbon dioxid has 
been passed through it. As milk ages, lactic acid begins to form 
and a stage is reached in which milk, which has previously had 
carbon dioxid passed through it, coagulates on boiling. At a 
second stage it coagulates on heating without the treatment with 
carbon dioxid. When the lactic acid is present in sufficient amount, 
the milk coagulates spontaneously at room temperature, forming 
a solid mass. The amount of lactic acid formed in milk depends 
both upon the amount of sugar in the milk and the type of or- 
ganism. The acidity may vary between 0.3% and 1.3%. In 
most instances, when a vigorous strain of organism is used, the 
amount of lactic acid varies between 0.5% and 0.6%. 6 

Kastle 7 studied the coagulation of sour milk in Washington. 
His results are given in Table 30 on page 148. 

The milk which coagulated spontaneously at 65° C. (145° F.) had 
an acidity of 0.711. As a general rule, the milks which are most 
easily coagulated by heat have the highest acidity. On the other 
hand, samples of milk with an acidity of 0.54% of lactic acid, which 
did not coagulate on boiling, have been reported. 8 Fresh milk, 

1 Courant: Uber die Reaction der Kuh und Frauenmilch. Inaug. Diss., 
Breslau, 1891, 9. 

8 Bahrdt and Edelstein: Zeitschr. f. Kinderh., 1914, xi, 403. 
8 Clark: Jour. Med. Research, N. S., 1915, xxvi, 431. 
4 Koppe: Jahrb. f. Kinderh., 1898, xlvii, 389. 

6 Hammarsten: loc. cit. 
fl Leischmann: Bact. acidi lactici. 

7 Kastle and Roberts, loc. cit. 

8 Stokes: Analyst, xvi, 22. 



160 COW'S MILK. CHEMISTRY AND BIOLOGY 



according to Richmond, 1 has an acidity of 20 degrees, correspond- 
ing to 0.18% lactic acid. He found that milk curdled on boiling 
when it had an acidity of 33 degrees, corresponding to 0.29% of 
lactic acid. 

TABLE 30 

The Relation op the Acidity and the Temperature op Milk to Coagu- 
lation (Kastle) 



Acidity 


Temp. 


Time of heating, 


Curdled = + 


per cent. 


°C. 


minutes 


Not curdled = — 


0.711 


65 





+ immediately 


.594 


65 


1 


+ 


.576 


65 


2 


+ 


.567 


65 


1 


+ 


.554 


60 


2 


+ 


.531 


65-67 


2 


+ 


.513 


65 


2 


+ 


.478 


60 


5 


+ 


.450 


65 


1H 


+ 


.441 


66 


l 


+ 


.387 


65 


5 


+ 


.351 


65-67 


2 


+ 


.342 


78.5 


2 


+ 


.342 


66 


5 


— 


.315 


70 


10 


+ 


.315 


70 


5 


+ 


.306 


75 


3 


— 


.306 


65 


5 


— 


.288 


70 


5 


— 


.261 


65-74 


5 


— 


.252 


100 


1 


— 


.252 


70 


5 


— 


.243 


100 


1 


— 


.243 


72-74 


10 


— 


.243 


65 


10 


— 


.234 


65 


5 


+ 


.225 


65-37 


2 




.198 


65 


5 


— 


.180 


65 


5 


— 



(b) Precipitation with Acids. — Casein may be precipitated from 
cow's milk by dilute acids. It requires 50 to 70 c. c. of N/10 hy- 
drochloric acid, or 60 to 80 c. c. of N/10 acetic acid to give the best 
results. When casein is treated with dilute acids, two chemical 
reactions take place: first the acid combines with the calcium in the 
casein, forming a base-free casein or a casein set free from its 

1 Richmond: Analyst, 1900, xxv, 121. 



COW'S MILK. CHEMISTRY AND BIOLOGY 161 

combination with calcium; on the addition of more acid, the casein 
molecule combines directly with the acid, forming a salt of the 
acid. This action is hastened by an increase of temperature. 
(Van Slyke.) 

It is supposed by Van Slyke to be an absorption of acid by the 
casein while Robertson believes that the acid goes in combination 
with the casein. Since such an excess of acid is not found in the 
physiology of the infant, casein may be considered as having the 
properties of an acid in subsequent discussions. 
An excess of acid will redissolve the precipitate. 1 
(c) Rennin Coagulation. 2, 3 — The following are some of the more 
important facts in reference to the action of rennin upon milk 
casein in causing coagulation: 

(I) The presence of soluble lime salts appears to be necessary 
for the coagulation of milk by rennin. 

(II) The reaction must be neutral to litmus, or acid, but not 
alkaline. Acids, whether organic or inorganic, although they differ 
from one another in respect to the intensity of the influence which 
they exert on the action of rennin, all have a very marked effect 
upon the coagulation of calcium casein by rennin. The usual 
explanation of this effect of acids upon the action of rennin is that 
the acid which is added dissolves the insoluble calcium phosphate 
of milk and thus increases the amount of soluble calcium salts. 
The claim is also made by some that the acid has in itself some 
direct influence upon the action of rennin. 

(III) The dilution of milk with water delays the coagulation 
of milk by rennin, because the proportion of soluble calcium salts is 
decreased. The addition of calcium chlorid or of a free acid to 
milk diluted with water not only hastens the time of coagulation, 
but also increases the amount of casein coagulated. 

(IV) Different chemical compounds affect the coagulation of 
milk by rennin in different ways. 

(V) The addition of foreign, inert matter, like starch or saw- 
dust, hastens rennin action. 

(VI) The temperature affects the rapidity of coagulation of 
milk by rennin. For complete action, the time decreases as the 
temperature increases. In a given time, rennin coagulates milk 
most completely at from 106° to 108° F., and less completely at 
temperatures above and below this point. 

1 Schlossmann and St. Engel in Konig: Der mensch. Nahrungs, u. Genus- 
mittel II, Berlin, 1914, 598. 

2 Van Slyke: Arch. Pediatrics, 1905, xxii, 515. 

3 Bosworth: Jour. Biol. Chem., 1913, xv, 231. 



162 COW'S MILK. CHEMISTRY AND BIOLOGY 

(VII) The temperature at which coagulation takes place affects 
the character of the coagulum. At 60° F. the curd is flocculent, 
spongy and soft; at from 77° to 113° F. it is more or less firm and 
solid; at 122° F. and above it is very soft, loose and more or less 
gelatinous. 

(VIII) Rennin heated for some time to over 140° F. becomes 
permanently weaker or inactive. It is somewhat affected at about 
120°F. Weak solutions are more easily affected by an increase of 
temperature than are strong solutions. 

(IX) An increase in the amount of rennin in proportion to the 
milk hastens the rapidity of coagulation as does also an increase in 
the strength of the rennin. 

(X) Freshly drawn milk curdles more completely than it does 
after it is allowed to cool. This is because it is warmer and per- 
haps because of the presence of carbon dioxid. 

(XI) Milk heated above 160° F. for a considerable length of 
time coagulates less rapidly than unheated milk. The coagulum of 
heated milk is highly flocculent, unless soluble calcium salts or 
some acid are added to it. Boiled milk is not coagulated normally, 
if at all, by rennin. 

Hammarsten was the first to show that the coagulation of milk 
by rennin was due to a soluble ferment which acted directly on the 
casein, producing, as he thought, two substances, the insoluble 
curd (Kase or paracasein), and a soluble product whey-protein 
(Molkeneiweiss). He also showed that the change of casein to 
paracasein was independent of coagulation, the coagulation being 
due to the presence of soluble calcium salts. 

A great number of papers have been published upon this subject 
since the early work of Hammarsten. As his explanation of the 
action of rennin has been generally accepted as correct, most of the 
recent investigations have been concerned with the influence of 
the soluble salts upon the coagulation. These investigations have 
shown that the soluble salts of calcium, barium and strontium 
favor or hasten coagulation, while the salts of ammonium, sodium 
and potassium retard or inhibit coagulation. 

Recently, Van Slyke and Bosworth 1 have shown that casein 
and paracasein are acids having the same percentage composition; 
that the molecular weight of casein is probably 8,888, while the 
molecular weight of paracasein is one-half that of casein, 4,444; 
that the combinations of casein with barium or strontium are 
insoluble in water while the combinations with one equivalent of 
ammonia, sodium, or potassium are soluble; and that ammonium, 
1 Van Slyke and Bosworth: Jour. Biol. Chem., 1913, xiv, 203-236. 



COW'S MILK. CHEMISTRY AND BIOLOGY 163 

sodium or potassium caseinates can be changed by rennin to para- 
caseinates which are soluble and are precipitated by calcium 
chlorid as calcium paracaseinates. 

These facts seem to indicate three things: 

First, that the action of rennin is the hydrolytic splitting of the 
casein molecule into two similar molecules of paracasein; perhaps 
in somewhat the same manner as maltose is split into two molecules 
of dextrose. 

Second, that it would seem doubtful if Hammarsten's whey- 
protein could be one of the products of rennin action. 

Third, that rennin is not, strictly speaking, a coagulating fer- 
ment, the coagulation of paracasein being due to the fact that the 
calcium paracaseinates are less soluble than the calcium caseinates, 
especially in the presence of the soluble salts of calcium, barium and 
strontium. The coagulation is, therefore, a secondary effect, the 
result of a change in solubilities. 

The curd formed in the coagulation of milk contains large 
quantities of calcium phosphate. Courant x believes that calcium 
caseinate on coagulation may carry down with it, if the solution 
contains dicalcium phosphate, a part of this as tricalcium phos- 
phate, leaving monocalcium phosphate in the solution. 

When the phenomena of coagulation of milk are watched under 
the ultra-microscope 2 the small particles of casein are seen to 
clump together before there is any visible gross coagulation. As 
more and more particles clump together they become visible. The 
milk of fresh cows is better suited to rennin coagulation than the 
milk of cows that are nearly dry. 

(d) The Effect of the Addition of Alkalies on the Curdling of 
Milk. — It is necessary to bear in mind the following facts, when 
considering the action of alkalies on casein. Bosworth and Van 
Slyke 3 have shown in a pretty series of experiments that " casein 
is a protein showing the characteristic property of an acid, in that 
it combines with metals or bases to form compounds known as 
caseinates.' ' For example, the compound of casein containing 
the largest amount of a monovolent metal-like sodium could be 
represented by the formula Na 8 casein (sodium caseinate); the 
corresponding calcium compound is Ca4 casein (calcium caseinate). 
It has not been definitely settled yet which particular compound of 
calcium is present in milk, but it is probably either tetra-calcium 
or tricalcium caseinate. When the calcium caseinate of milk is 

1 Courant: loc. cit. 

2 Kreidl and Neumann: Pfluger's Arch, 1908, 123, 523. 

3 Bosworth and Van Slyke: Am. Jour. Dis. Child., 1914, vii, 298. 



164 COW'S MILK. CHEMISTRY AND BIOLOGY 

acted on by rennin, it is changed into another compound called 
calcium paracaseinate. As the result of this action one molecule 
of calcium caseinate is split into two molecules of calcium paracase- 
inate. This reaction may be represented in the following formula: 
Ca4 caseinate = Ca2 paracaseinate + Ca2 paracaseinate. Para- 
casein, like casein, possesses acid properties, but it only has one- 
half the combining power of casein. Calcium paracaseinate is less 
soluble than the corresponding calcium caseinate present in the 
milk from which it is formed, and, therefore, when milk curdles, 
it is precipitated as a solid. If rennin is added to a solution of 
sodium caseinate the caseinate is split into two molecules of sodium 
paracaseinate, but no precipitation or curdling takes place. This 
is explained by the fact that sodium caseinate is very soluble. If a 
small amount of a soluble calcium salt (calcium chlorid) is added 
to the solution of sodium paracaseinate, curdling occurs at once, 
the curd being calcium paracaseinate. This chemical reaction 
may be illustrated in the following manner: 

Sodium paracaseinate (soluble) + calcium chlorid = calcium 
paracaseinate (insoluble) + sodium chlorid. The following table 
(Bosworth and Van Slyke) illustrates the effect of increasing 
amounts of sodium citrate on the coagulation of milk: 

TABLE 31 
Effect of Sodium Citrate on the Curdling of Milk by Rennin 



Grains of sod. citrate 


Amt. rennet solution 


Minutes required for 


to 1 oz. of milk 


used per 100 c. c. 


milk to curdle 


0.0 


2. 


6 


0.20 


2. 


7V 2 


0.40 


2. 


sy 2 


0.65 


2. 


n 


0.85 


2. 


31 


1.00 


2. 


37 


1.25 


2. 


47 


1.50 


2. 


62 


1.70 


2. 


not curdled 


1.90 


2. 


not curdled 


2.10 


2. 


not curdled 



The addition of increasing amounts of sodium citrate to milk 
lengthens the coagulation time of the milk up to the point when 1.7 
grains per ounce is added, after which the milk does not coagulate. 
In actual practice the addition of this amount prevents the forma- 
tion of a curd in the infant's stomach. The explanation of this 



COW'S MILK, CHEMISTRY AND BIOLOGY 165 

fact is that the sodium replaces some of the calcium in the caseinate 
and forms sodium caseinate of calcium-sodium caseinate. When 
rennin is added this double salt is changed to calcium sodium 
paracaseinate, which, owing to the presence of sodium, is not 
curdled. 

Lime Water. — "When lime water is added to cow's milk un- 
til it is neutral or faintly alkaline to phenolphthalein, a basic 
calcium casein is formed which is not acted upon by rennet and 
will not form a curd even in the presence of lime salts." l This 
results from the precipitation of the calcium phosphate in the 
form of insoluble di- and tricalcium phosphate. The soluble cal- 
cium phosphate may be so reduced in cow's milk by this pro- 
cedure that there is less than is present in human milk. 2 In actual 
practice the addition of lime water to milk may increase its alka- 
linity to such a point that the stomach will not secrete the requisite 
amount of acid to make the stomach contents neutral or acid. 
A neutral or acid reaction is necessary for the coagulation of milk 
by rennin. 

Anti-rennin may be formed by injecting rennin into horses until 
a ferment is formed which destroys the action of rennin. 3, 4 When 
it is added to milk with rennin it prevents the coagulation of 
milk. 

The Chemical Composition of Cow's Milk. — The individual 
food components, fats, lactose, proteins and salts will be con- 
sidered separately and then as a whole. The variations in the 
composition of the milk of a single cow is only of slight interest in 
this connection, because the milk used in infant feeding is in 
almost all instances mixed milk. 

Nitrogenous Bodies. — The following table, compiled by Leach, 5 
gives a good idea of the average amounts of the various food 
components and also of the extreme variations in their per- 
centages: 

1 Van Slyke: Archives of Pediatrics, xxii, 515. 

2 Bosworth and Bowditch: Jour. Biol. Chem., 1917, xxviii, 431. 
8 Hammarsten: loc. cit. 

4 Morgenroth: Centr. Bakt., 1900, xxvi, 349; Fuld and Spiro: Zeitschr. 
phys. Chem., 1900, xxxi, 132. 

5 Leach: Food Inspection and Analysis, New York, 1907. Table compiled 
from Koenig's Chemie der Menschlechen Nahrungs und Genussmittel. 



166 COW'S MILK, CHEMISTRY AND BIOLOGY 

TABLE 32 



Cow's milk 


Specific 
gravity 


Water 


Casein 


Albu- 
min 


Total 
protein 


Fat 


Lac- 
tose 


Ash 


Minimum 

Maximum 

Average 


1.026 
1.037 
1.031 


80.32 
90.32 

87.27 


1.79 
6.29 
3.02 


0.25 
1.44 
0.53 


2.07 
6.40 
3.20 


1.67 
6.47 
3.64 


2.11 
6.12 

4.88 


0.35 
1.21 
0.71 



Table 33 shows how much the composition of the morning and 
evening milk may vary. These figures are the average from 
29,707 tests of milk made by Droop Richmond in England. 

TABLE 33 



Milking 


Fat 
per cent. 


Lactose 
per cent. 


Protein 
per cent. 


Ash 
per cent. 


Solids 
per cent. 


Morning. . . 
Evening. . . 


3.44 
3.90 


4.71 
4.69 


3.43 
3.39 


0.74 
0.73 


12.34 
12.71 



Cows of different breeds give milk of somewhat different com- 
position and, although it was supposed that cattle from mountain 
regions gave a richer milk than those from the lowlands, there are 
many exceptions to this statement. 1 The Jersey and Guernsey 
breeds give a rich milk and the Holstein and Ayrshire cattle are apt 
to give a milk poorer in fat but this is more suitable for infant 
feeding. The fat globules in the Jersey milk are almost three times 
that of the Holstein. The milk of different individuals of the 
same herd and species vary in composition and it is fair to assume 
that the production of rich milk is distinctly an "individual prop- 
erty that is due to the physiological peculiarities of the gland 
cells of the animal, and which to a great degree is hereditary." 
(Jensen.) 

Nitrogenous Compounds. — The total nitrogenous compounds 
are given by Van Slyke as 3.2% and by Babcock as 3.8%. The 
principal proteins are casein and albumin, or insoluble and soluble 
proteins. The principal soluble proteins are lactalbumin and lac- 
toglobulin. There are probably other substances also, but little 
is known about them. The figures as to the relation of the casein 
to the soluble nitrogenous bodies in the milk vary greatly, being all 
the way from 2.6:1 2 to 8:1. 3 The average according to Van Slyke 

1 See Jensen's Milk Hygiene, Phila. and London, 1907. 

2 Van Slyke : Archives of Pediatrics, 1905, xxii, 509. 

3 Stohmann: Milch und Molkereiproducte 1898, 58, quoted by Czerny and 
Keller; Hammarsten: Jahresber. f. Thierchemie, 1896, xxv, 206; Schloss- 
mann: Verh. d. 13 Vers. d. Gesellsch. f. Kinderh. in Frankfurt, 1896, 78. 



COW'S MILK, CHEMISTRY AND BIOLOGY 167 

is 3.6 parts of casein to one part of soluble protein. (In human 
milk the relation is approximately 1 :2.) Table 32 shows that the 
amount of casein and albumin in cow's milk may vary materially. 

Casein. — Cow casein is a white powder, with a specific gravity of 
1.259. It causes moist blue litmus paper to turn red and shows the 
characteristic properties of an acid, in that it combines with metals 
or bases to form compounds known as caseinates. 1 One gram 
of ash-free casein develops 5.742 calories according to Schloss- 
mann; 2 5.85 according to Sherman. 3 The molecular weight of 
casein is 8888. 4 It has the following composition: C. 53.0; H. 7; 
N. 15.7; S. 0.8; P. 0.85; O. 22.65%. 2 

The question whether the casein from different kinds of milk is 
identical or whether there are several caseins cannot be decided by 
the elementary composition. 5 It is probable that chemically they 
are much the same, but that biologically they are different. (See 
Human Casein.) 

Casein dissolves readily in water with the aid of alkali or alkaline 
earths, also calcium carbonate from which it expels carbon dioxid. 
Such solutions are precipitated by dilute acids and redissolved by 
stronger acids (s. 5-2.8 grams HO to 10.0 grains casein). It is 
insoluble in alcohol and water. 

The casein in milk is in combination with calcium in the form 
of calcium caseinate. It has not been definitely settled as yet 
which particular compound is in milk, but it is probably either 
tetra-calcium or tri-calcium caseinate. 6 

Osborne and Guest 7 have shown by hydrolysis that casein 
contains glycocoll 0%, alanine 1.5%, valine 7.2%, leucine 9.35%, 
proline 6.7%, phenylalanine 3.2%, glutaminic acid 15.55%, as- 
partic acid 1.39%, cystine series 0.5%, tyrosine 4.5%, oxyproline 
0.23%, histidine 2.50%, arginine 3.81%, lysine 5.95%, trypto- 
phane 1.5%, diaminotrioxy dodecanic acid 0.75%, NH 3 1.61%, S. 
0.76%, P. 0.85%. The figures quoted by Raudnitz 8 vary some- 
what from these. 

Paracasein. — Paracasein is a body closely related to casein. 
The transformation of casein into paracasein is a process of hy- 
drolytic splitting, one molecule of casein yielding two molecules 

1 Bosworth and Van Slyke: Am. Jour. Dis. Children, 1914, vii, 298. 

2 Schlossmann: quoted by Raudnitz in Sommerf eld's Handbuch. 

3 Sherman: Chemistry of Food and Nutrition, N. Y., 1911, 123. 

4 Van Slyke and Bosworth: Jour. Biol. Chem., xiv, 1913, 231. 
6 Hammarsten: Textbook of Phys. Chem., N. Y., 1912, 615. 

6 Bosworth and Van Slyke: Am. Jour. Dis. Children, 1914, vii, 298. 

7 Osborne and Guest: Jour. Biol. Chem., 1911, ix, p. 333. 

8 Raudnitz: Sommerf eld's Handbuch der Milchkinde, Wiesbaden, 1909. 



168 COW'S MILK, CHEMISTRY AND BIOLOGY 

of paracasein 6 When paracasein is in combination with a salt 
the compound is known as the paracaseinate of that salt. For 
instance the combination with calcium is known as calcium para- 
caseinate. It has been shown above that calcium paracaseinate 
is insoluble, while sodium, potassium and ammonium paracase- 
inate are soluble. Calcium paracaseinate is similar to calcium case- 
mate, but it cannot be recoagulated by rennin. 

Lactalbumin. — Lactalbumin, one of the components of whey 
protein, has the following composition: C. 52.19, H. 7.18, N. 15.77, 
S. 1.73, O. 23.13%. 2 When compared to casein, the most strik- 
ing differences are that it contains more sulphur and no phos- 
phorus. 

Lactoglobulin. — Lactoglobulin is very similar in its composition 
to serum globulin. It is present in only small amounts in normal 
milk, but in larger amounts in colostrum. 1 

Extractives. — There are traces of urea, creatine, creatinine, 
hypoxanthine (?) and cholesterine in cow's milk. 2 

Whey. — Whey is an opalescent solution which remains after the 
coagulation of casein. It contains lactalbumin, lactoglobulin and 
extractives. Most of the solid portion of the whey of cow's milk is 
lactalbumin, while the rest, a small part, is divided among the 
other components. Although the analyses of whey are essentially 
the same as the analyses of lactalbumin, they are reported in a 
separate paragraph. The whey from cow's milk, according to 
Konig 3 contains: water 93.8%, total ash 0.44%. The ash con- 
tains K 2 30.77%, Na 2 13.75, CaO 19.25, Mg. 0.036, F2O3 0.55, 
P2O5 17.05, S0 3 2.73, CL 15.15. 

Fat. — The percentage of fat in the mixed milk of herds may be 
maintained at 4% by carefully testing and selecting the cows. It is 
such 4% milk that should be used in infant feeding. The problems 
incident to maintaining the percentage of fats at the required 
amount do not concern the pediatrician, and, therefore, will not be 
considered. 

The fat droplets are exceedingly small. Their diameter varies 
from 0.0024 to 0.0046 m. m. There are 1.06 to 5.75 millions of fat 
drops to the cubic m. m. 4 It is possible that the fat droplets are 
maintained in a state of emulsion because they are surrounded 
by a covering of casein which prevents the globules from uniting 

6 Bosworth: Jour. Biol. Chem., 1914, xix, 397. 

1 Sebelien: quoted by Voltz in Oppenheimer's Handb. loc. cit. s p. 390. 

2 Hammersten: Textbook of Phys. Chem., N. Y., 1912. 

3 Konig: loc. cit. 

4 Woll: Wisconsin Exp. Station, vi, 1892. 



COW'S MILK, CHEMISTRY AND BIOLOGY 169 

with one another, 1 or that they are surrounded by a membrane. 2 

The fat of cow's milk is chiefly of olein and palmitin. It also 
contains triglycerides, butyric acid, myristic acid, stearic acid, 
small amounts of lauric acid, arachidic acid and dioxystearic acid, 
as well as caproic acid, traces of caprylic acid and capric acid. 3 
The fat of milk contains small quantities of lecithin, cholesterin, 
and a yellow coloring matter. This yellow coloring matter, accord- 
ing to Palmer and Eckles 4 is carotin and xanthophyll, especially 
the former which is a well known yellow vegetable pigment found 
accompanying chlorophyll in all green plants. The pigment comes 
from the food, especially green grass. It is possible that the qual- 
ity of the food may influence the composition of the fat. 

Lactose. — Milk sugar is easily soluble in water and does not 
ferment with pure yeast. The extreme variations in the per- 
centage of milk sugar in cow's milk are 2.11% and 6.12%, the 
average being 4.88%, 5 according to some authors, and 4.60% 
according to others. 6 

Lecithin. — Cow's milk contains between 0.048 gm. and 0.058 gm. 
of lecithin. 7 

Some investigators maintain, however, that these figures repre- 
sent a mixture of lecithin and kephalin. 8 

Salts. — The total ash in cow's milk is generally given as 0.7%, 
the extreme limits being 0.6% and 1.0%. 9 

1 Quincke: Pfluger's Arch. xix. 

2 Abderhalden and Voltz: Zeitschr. f. phys. Chem., lix. 

3 Hammarsten: loc. cit. 

4 Palmer and Eckles: Jour. Biol., Chem., 1914, xvii, 191. 
6 Leach: loc. cit. 

6 Fleischmann: Lehrbuch der Milchwirtschaft, Bremen, 1898, xi, 43, quoted 
by Czerny and Keller, I, 437. 

7 Bunge: Zeitschr. f. Biologie, 1874, x, 309. 
8 Schloss: Uber Sauglings-Ernahrung, Berlin, 1912, 55. 

'Soldner: Die Landwirthsch. Versuchstat, 1888, xxxv, 361, quoted from 
Voltz in Oppenheimer's Handbuch, III, I, 398. 



170 COW'S MILK. CHEMISTRY AND BIOLOGY 



TABLE 34 

Percentage of Salts in Cow's Milk in 100 Parts of Ash 





Abder- 








Bunge l 


halden* 


Schloss 8 


Soldner 


Pelka 2 


22.14 


22.40 


24.74 


24.96 


23.75 


13.91 


12.25 


10.79 


6.16 


15.36 


20.05 


21.07 


21.35 


22.25 


20.37 


2.63 


2.91 


2.71 


2.71 




0.04 










24.75 


24.10 


29.54 


32.27 


27.13 


21.27 


17.25 


13.63 


10.86 


14.67 



Rich- 
mond 4 



K 2 0. 
Na 2 
CaO. 
MgO. 
Fe 2 3 
P 2 5 . 
(CL). 



28.71 
6.67 

20.27 

2.80 

.40 

29.33 

14.00 



One liter of cow's milk contains in grams: 





Soldner 3 


Schloss 2 


K 2 


1.72-1.885 

0.51-0.465 

1.98-1.72 

Q. 20-0. 205 

1.82-2.437 

0.98-0.82 


1.849 


Na 2 


0.861 


CaO 


1.650 


MgO 


0.215 


P 2 5 


2.183 


CL 


1.091 







K 2 0. 

Na 2 0. 

CaO. 

MgO. 

p 2 o 5 . 

CL.. 



100 grams of the Ash of Cream contains in grams: 5 




Citric Acid. — Cow's milk contains about 0.2% of citric acid. 6 
Milk conducts electric currents because of the presence of salts 
of various kinds. The electrical conductivity of cow's milk is 
43.8.11-4, and of human milk 22.6. 10-4. 7 Koeppe concludes from 
these figures that 58% of the molecules in cow's milk and 26% of 
those in human milk are dissociated. 



1 Bunge: Zeitschr. f. Biologie, 1874, x, 309. 

2 Schloss: tiber Sauglings-Ernahrung, Berlin, 1912, 

3 Soldner: Die Landwirthsch. Versuchstat. 1888, 
Voltz in Oppenheimer's Handbuch, III, I, 398. 

4 Richmond: Dairy Chemistry, Phila., 1899. 

5 Schloss : loc. cit. 

6 Soldner: Zeitschr. Biol., 1896, xxxiii, 43, 535. 

7 Koeppe: Jahrb. f. Kinderh., 1898, xlvii, 389. 



55. 



361, quoted from 






COW'S MILK. CHEMISTRY AND BIOLOGY 171 

FROZEN MILK 

Very little is known as to the chemical changes which take place 
in milk when it is frozen. It is supposed by some investigators 
that the casein is changed by the freezing into a more permanent 
compound. 1 Mai 2 concluded, however, that the freezing and 
thawing of milk causes no permanent change in its composition. 

Pennington 3 and her collaborators found very definite changes 
in milk after freezing. They found that when the milk is held at a 
temperature of 0° C. (length of time not stated), there is pro- 
teolysis of the casein, which is primarily of bacterial origin, and 
proteolysis of the lactalbumin, due primarily to the native enzymes 
of the milk. The action of these two agents together is more 
rapid than that of either agent alone. The bacteria and enzymes 
may break down the true protein and carry the breaking down 
through peptones even to amino acids. There is a fermentation of 
lactose with the formation of lactic acid, which is largely, if not 
exclusively, due to bacterial action. The fat, so far as can be 
determined, is not affected except by the action of bacteria. 

Some bacteria disappear from the milk while it is frozen, while 
others may increase rapidly, especially if the milk is raw. The 
rate of increase in the number of bacteria depends upon their 
previous surroundings and upon the rapidity with which they 
become acclimated to their surroundings. There is apt to be very 
little increase in the first four or five days, after which there is a very 
rapid increase in numbers. There is no information concerning 
the chemical changes which take place in milk that has been frozen, 
from only twenty-four hours to forty-eight hours. The predomin- 
ating organisms which they found were the micrococcus aurantia- 
cus (Cohn), and the micrococcus ovalis (Escherich) both of which 
belong to the acid forming group. 

1 Engling: Landw. Vers. Stat., 1888, xxxi, 391 ; Siegfried and Bischoff : quoted 
by Raudnitz in Sommerf eld's Handbuch, 201. 

2 Mai: Z. Nahr. Genussm., xxiii, 250 from chemical abstr., Sept. 20, 1912. 

3 Pennington, Hepburn, Witner, Stafford and Burrell: Jour, of Biol. Chem., 
1913, xvi, 331. See also Pennington: Jour. Biol. Chem., 1908, iv, 353; Hep- 
burn: Jour, of the Franklin Ins., 1911, clxxii, 187. 



172 COW'S MILK. CHEMISTRY AND BIOLOGY 



TABLE 35 

Comparative Composition op Milks op Different Animals Taken from 

Voltz 1 



Milk 



Human 

Cow 

Buffalo 

Zebu (1 analysis). . 
Lama (3 analyses. 
Camel (7 analyses) 

Goat 

Sheep 

Reindeer 

Mare 

Donkey 

Elephant 

Hippopotamus 

(1 analysis) 

Rabbit 

(1 analysis) 

Guinea pig 

(1 analysis) 

Dog (8 analyses) . . 
Cat 

Pig 

Blue Whale 











Total 




Water 


Solids 


Fat 


Casein 


N. 


Sugar 


87.58 


12.42 


3.74 


0.80 


2.01 


6.37 


87.80 


12.20 


3.40 


2.70 


3.40 


4.70 


82.30 


17.70 


7.70 




4.80 


4.40 


86.13 


13.87 


4.80 




3.03 


5.34 


86.55 


13.45 


3.15 


3.00 


3.90 


5.60 


87.60 


12.40 


5.38 


2.98 




3.26 


86.30 


13.70 


4.00 


3.60 


4.60 


4.30 


81.50 


18.50 


7.00 


4.30 


5.60 


5.00 


67.70 


32.30 


17.10 




10.90 


2.80 


90.58 


9.42 


1.14 




2.50 


5.87 


90.12 


9.88 


1.37 


0.79 


1.85 


6.19 


67.85 


32.15 


19.57 




3.09 


8.84 


90.43 


9.57 


4.51 








69.50 


30.50 


10.45 




15.54 


1.95 


41.11 


58.89 


45.80 




11.19 


1.33 


77.00 


23.00 


9.26 


4.15 


9.72 


3.11 


81.64 


18.36 


3.33 


3.11 


9.53 


4.91 


82.37 


17.63 


6.44 




6.09 


4.04 


50.47 


39.53 


20.00 




12.42 


5.63 



Ash 



0.3 2 
0.7 3 
0.8 4 
0.7 5 
0.8 6 
0.7 7 
0.8 8 
0.9 9 
1.50 10 
0.36 " 
0.47 12 
0.65 13 



2.56 14 

0.57 15 
0.91 16 
0.59 17 
0.59 13 
1.48 19 



1 Oppenheimer's Handbuch der Biochemie, iii, Jena, 1910, 403. 

2 J. Konig: D. mensch. Nahrungs u. Genussmittel 1904, Berlin, ii, 598. 

3 Kirschner: Hand. d. Milchwirtschaft, Berlin, 1907, pp. 7 and 40. 

4 Kirschner (see above). 

5 Konig (see above). 

6 Konig (see above). 

7 Barthe: quoted in Malys Jahresber., 1906, 230. 

8 Kirschner (see above). 

9 Kirschner (see above). 

10 Fleischmann: Lehrb. d. Milchwirtschaft, 3rd ed., Leipzig, 1901, 67. 

11 Kirschner (see above). 

12 Kirschner (see above). 

13 Hammarsten. 

14 Konig (see above). 

15 Konig (see above). 

16 Konig (see above). See also Gruinner, Biochem. Zeitschr., 1915, lxviii, 
311. 

17 Camaille, C. R. 63, 692. 

18 Hammarsten. 

19 Backhans quoted in Maly's Jb. 1906, 299. 






COW'S MILK. CHEMISTRY AND BIOLOGY 173 

Rosenau * found that freezing milk for forty-eight hours did not 
influence its restraining action on the growth of the typhoid bacil- 
lus, but destroyed it for the B. lactis aerogenes. 



GOATS MILK 

Goats are seldom infected with tuberculosis. 2 This does not 
mean, however, that they are immune and never have the disease. 

The goat may secrete ten times its own weight in milk in a 
year's time. 3 It produces the most milk during the hot summer 
months. 

The composition of goat's milk as given by various authors is 
as follows : 

TABLE 36 



Per cent. 


Ellen- 
burger 4 


Hucho 5 


Abder- 
halden* 


Voelcker 7 


Ander- 
egg 8 


Schaf- 
fer* 


Steineg- 


of 


1 

7.02 

5.28 

4.67 
1.01 


2 
7.11 

4.68 

3.94 
0.79 


3 


ger 


Fat 

Lactose 

Casein 

Albumen. . . . 
Total protein. 

Ash 


6-7 

4.5 

2.8 

0.51 

3.35 

0.895 


2.50- 
5.10 
3.76- 
5.46 

2.25- 
3.89 
0.72- 
0.98 


2.93 

3.92 

2.56 
0.58 
3.14 


7.34 
5.99 

3.19 
0.77 


4.6 
4.3 

1.03 
3.5 

0.51- 
0.93 


2.14- 
4.72 

2.07- 

4.77 

2.3- 
4.38 
0.63 


3.25 
2.80 

3.92 
0.63 



The composition of goat's milk is very similar to that of cow's 
milk. It is different, however, in that it is pure white instead of 
golden white in color. Goat's milk has a characteristic odor when 
it is milked in the stable and the odor of the animals pervades the 
air. This odor is more marked when the male is present in the 
same stall as the female. 

The fat drops in goat's milk are somewhat smaller than those in 

1 Rosenau: Hygienic Laboratory, Bulletin No. 56, Washington, 1909, 487. 
2 Richter: Berliner klin. Wochenschr., 1888, No. 18; Schwartz: Deutschr. 
med. Wochenschr., 1896, No. 40. 

3 Fleischmann: Lehrbuch d. Milchwirtschaft, 2nd ed., 1898, 65 (C. & K). 

4 Ellenburger: Arch. f. physiol., 1899, p. 48. 

6 Hucho: Yahresber f. physiol. Chemie, 1899, xxvii, 440. 

•Abderhalden: Zeitschr. f. physiol. Chemie, 1899, xxvii, 440. 

'Voelcker: Milchzeitung, 1881, x, 151 (3 goats). 

8 Anderegg: Sandw. Wochenbl., 1893, xix, 290 and 330 (C. & K). 

'Schaffer: Schweizer, Wochenschr., f. Pharmacie, xxxi, 58 (C. & K.). 



174 COW'S MILK. CHEMISTRY AND BIOLOGY 

cow's milk. The casein coagulates more quickly with rennin than 
does that of cow's milk. 1 The casein precipitates out in compact 
masses, which are colored white and have a fine structure. When 
this casein undergoes pepsin-hydrochloric acid digestion, 12% re- 
mains undigested. 

Konig 2 found the average composition and the extreme varia- 
tions in 100 analyses to be as follows: 

TABLE 37 





Average 


Variations 


Water 


86.88 % 
4.07 % 
4.63 % 
3.76 % 
0.85 % 
1.030% 


82.02 -90.16% 


Fat 


2.29 - 7.55% 


Lactose 


2.80 - 5.72% 


Protein 


3.32 - 6.50% 


Ash 


0.35 - 1.36% 


Specific gravity 


1.028- 1.036% 



The composition of goat's milk is influenced by the same factors 
and in the same manner as cow's milk. 

1 Devarda: Landw. Versuchsst. xlvii, 416; Steinegger: Milch Ztg., 1898, 
No. 23. Quoted by Burr in Sommerfeld, — loc. cit. 

8 Konig: Molkerei-Ztg. Hildesheim, 1897, pp. 617, 635, 653. 






CHAPTER XIV 
COW'S MILK: BACTERIOLOGY AND CHEMICAL TESTS 1 

There are two types of bacteria found in milk, the non-patho- 
genic and the pathogenic. The ideal milk would be one which con- 
tained no bacteria but this is very difficult to obtain because bac- 
teria find their way into the udder through the opening in the teat. 
These bacteria are washed out in the fore-milk which is rejected 
for this reason, by those producing clean milk. 

The commonest bacteria in milk are those producing souring, 
of which the lactic acid bacteria are the most common. These bac- 
teria produce so much acid in the milk that they gradually crowd 
out other organisms which cannot grow in the acid surroundings. 
Lactic acid bacteria are not found in milk when it leaves the udder, 
but enter the milk when it is exposed to air. The commonest lac- 
tic acid forming bacteria are the Bacillus lactis acidi or Streptococ- 
cus lacticus. They grow best in anaerobic media. A less common 
form is the B. lactis aerogenes. 

Of the bacteria which may produce disease in man and cause 
souring of milk, the colon bacillus is common. It is derived from 
the manure of the cow. Streptococci, which cause inflammation 
of the udder of the cow, may sour the milk and cause disease in 
those drinking it. There are some one hundred varieties of 
bacteria which may lead to lactic acid fermentation and souring 
of milk. 

The class of organisms known as putrefactive bacteria may im- 
part a bad odor to the milk and cause diarrhea in children either 
through their own action or by the products of their activity. 
They enter the milk in manure and filth. They may liquefy and 
digest casein. 

Another group of bacteria apparently has no action on the milk 
and is not harmful to the consumer. 

Butyric acid bacteria form butyric acid by splitting up the fat in 
rancid butter. Yellow, red, blue, brown and green milk are rarely 
seen and the particular coloration is due to changes produced in 
the milk by special bacteria. A turnip taste is often given milk by 

1 Winslow: The Production and Handling of Clean Milk, New York, 1909, 
has been freely used in this section. 

175 



176 COW'S MILK, BACTERIOLOGY 

the B. foetidus lactis. Slimy milk, and bitter, stringy, and soapy 
milk are due to other special bacteria. Bitter milk may, however, 
be produced by other causes than the growth of bacteria, as by 
certain foods which the cow may eat (lupines, ragweed, wormwood, 
cabbages, raw Swedish turnips). Inflammation of the udder or 
garget may also cause the milk to be bitter. 

Red milk may be due either to blood or the cow's eating large 
amounts of sedges, rushes, madder root, alkalet, field horsetail, 
meadow saffron, and knot grass. A red yeast may cause the cream 
to turn pink after standing two days. 

Slimy milk may be due to pus or to the B. lactis viscosus, which 
comes chiefly from water and dust. 

Pathogenic Bacteria in Cow's Milk. 1 — The tubercle bacillus is 
found frequently in cow's milk when the animal is affected with 
tuberculosis of the udder. It is also found in milk when the udder 
is healthy and there is disease in other parts of the body, viz., 
the bowel or uterus, the excretions of which fall into the milk. 
The secretion from a diseased lung is swallowed and may be spat- 
tered into the milk pail. The tubercle bacillus may also get into 
milk from consumptives who are working around the cattle, either 
from their hands or expectoration. 

Theobald Smith 2 and others have shown that there is a differ- 
ence between the human and bovine type of the tubercule bacillus. 
Recent pathological investigations show that the bovine type of 
the tubercle bacillus may be the cause of tuberculosis in human 
beings, especially in the infant and young child. 3 

Other pathogenic bacteria which may grow in milk and have 
been the etiological cause of epidemics are the typhoid bacillus, the 
diphtheria bacillus, the streptococcus, and the organism that causes 
scarlet fever. The milk is usually infected after it has been milked 
by the hands of the milker, the air and dust in the stable, the milk 
pail, the water supply, the milk cooler, cans or bottles. The 
organisms get into the milk from the outside. 

Other organisms which have not been reported as the cause of 
epidemics, but which are of pathological significance in cow's milk 
are the dysentry bacillus (both Shiga and Flexner types), the gas 
bacillus, the staphylococcus, bacteria of the colon group, the 

1 Weber, A. : In Sommerfeld's Hand, der Milchkunde, Wiesbaden, 1909, 
405, is used freely in this section. The original may be consulted for the 
literature. 

2 Smith, Theobald: U. S. Dep't Agric. Bureau of Animal Ind., 12 and 13, 
Washington, 1897; Jour. Exp. Med., 1893, iii. 

3 Von Behring and Smith, T. : British Royal Commission on Tuberculosis. 



COW'S MILK: BACTERIOLOGY 177 

bacillus of anthrax, actinomyces, and the organisms of cow pox, 
hydrophobia, foot-and-mouth disease and cholera. 

"Milk sickness" * is a disease of sparsely settled communities 
which has been described only in America. It is due to a motile 
rod with flagella, the Bacillus lactimorbi, which has been demon- 
strated by Jordan and Harris. 2 In cattle it causes the disease 
known as " trembles." It is very fatal to man. 

The bacillus of contagious abortion 3 is practically always pres- 
ent in artificial milk produced around San Francisco, but it is 
not pathogenic to infants. 4 Whether it has any connection with 
abortion miscarriage in the human is as yet unknown. Larson 
and Sedgwick 5 have found that the blood of many women who 
have aborted gives the complement fixation test to the Bacillus 
abortus as does the blood of many children. 

Caloric Value of Milk. — It is obvious that the caloric value 
of milk depends upon its composition. Since the composition of 
cow's milk varies considerably the caloric value also varies. The 
figures most generally accepted are those of Rubner who found 
that 1000 grams of milk gave between 622 and 690 calories. 
Heubner uses 670 calories as the average caloric value of cow's 
milk. 

Milk Preservatives. 6 — The most commonly used preservatives 
are formaldehyde, borax and boric acid. Occasionally salicylic 
acid and sodium carbonate are employed. 

Formaldehyde may be detected in milk in the following man- 
ner: Place about twenty cubic centimeters of milk in a small glass 
vessel, dilute with an equal volume of water, and add commercial 
sulphuric acid, allowing it to flow slowly down the inside of the 
vessel. If formaldehyde is present a purple color will appear at 
the junction of the acid and milk. 

Boric acid or borax are detected by adding a drop or two of 
hydrochloric acid to a few drops of milk in a white dish and then 
several drops of a saturated alcoholic solution of turmeric. The 
dish is then heated gently for a few minutes and, if boric acid or 
borax are present, a pink or dark red color will appear. A dark 

1 McCoy: Treasury Dep't, Hygienic Laboratory Bull. 56, Wash., 1908, 
217. 

8 Jordan and Harris: Jour. A. M. A., 1908, L. 1665. 

3 Fabyan: Jour, of Med. Research, xxvi, No. 3; xxviii, No. 1; Larson: Jour. 
Inf. Dis., 1912, 178. 

4 Fleischner and Meyer: Am. Jour. Dis. Ch., 1917, xiv, 157. 

5 Larson and Sedgwick: Am. Jour. Dis. Children, 1913, vi, 326. 

6 Taken from K. Winslow: The Production and Handling of Clean Milk, 
N. Y., 2nd Edition, 1909. 



178 COW'S MILK: BACTERIOLOGY 

blue-green should appear when the dish is cooled and a drop of 
ammonia added. 

Sodium carbonate is detected by adding an equal volume of 
alcohol and then two drops of a 1% solution of rosolic acid to the 
suspected sample of milk. If sodium carbonate is present a red- 
rose color will appear. The test may be performed with more 
certainty if a control test is made at the same time with a sample 
of milk known to be pure. 

Salicylic acid is rarely used as a preservative. It may be de- 
tected by adding a few drops of sulphuric acid to a small quantity 
of milk and then shaking gently with a mixture of equal parts of 
ether and petrolic ether. Equal volumes of acidulated milk and 
the ether mixture should be taken. The upper ethereal solution is 
poured off after standing for several hours and the remaining 
liquid is evaporated in a porcelain dish. A few drops of water and 
a drop of ferric chlorid solution will produce a violet or purple 
color on being added to the solution if salicylic acid is present. 

Babcock test (see page 229). 

Estimation of total solids (see page 229). 



CHAPTER XV 

STERILIZATION, BOILING AND PASTEURIZATION OF 

MILK 

The term, " sterilization/ ' should never be applied to the proc- 
essses used in the preparation of milk for the feeding of infants, 
because the milk is never rendered bacteriologically sterile by 
them. The term "pasteurization," as it is ordinarily used, is 
indefinite and misleading. It should always be stated at what 
temperature the milk is heated and how long it is kept at this 
temperature; otherwise, it means nothing. In Massachusetts 
pasteurized milk is defined by law to be natural cow's milk not 
more than seventy-two hours old when pasteurized, subjected for 
a period of not less than thirty minutes, to a temperature of not 
less than one hundred and forty degrees nor more than one hun- 
dred and forty-five degrees Fahrenheit, and immediately there- 
after cooled therefrom to a temperature of fifty degrees Fahren- 
heit or lower. 

THE CHANGES PRODUCED IN MILK BY HEAT 

Appearance, Taste and Smell. — A well-marked scum, or pel- 
licle, develops on the surface of boiled milk. This may begin to 
develop at as low a temperature as 122° F. (50° C.) (Pfaundler and 
Schlossmann). 1 This is due to the disassociation of the casein 
compounds as the result of drying. Its composition is: 

Fatty matter 45.42% 

Casein and albuminoid 50 . 86% 

Ash 3.72% (Rosenau) 

Changes in the taste and smell may develop at as low a tem- 
perature as 158° F. (70° C.) (Sommerfeld), 2 but are usually not 
marked unless the milk is brought nearly to the boiling point. 
Prolonged boiling changes the color toward brown, the amount of 
change depending on the duration of the boiling. The change in 

1 Pfaundler and Schlossmann: The Diseases of Children, 1908, i, 303. 

2 Sommerfeld: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden, 1909. 

179 



180 COMPOSITION OF BOILED MILK 

color is due to the caramelization of the sugar. Heating at 150° F. 
(65° C), or over, for half an hour, materially delays or entirely 
prevents the rising of cream. This is because the normal agglutina- 
tion of the fat droplets is broken down and they are more homoge- 
neously distributed throughout the fluid (Rosenau). 1 

Composition. — When milk is boiled there is a partial fixation 
of the calcium salts, which are probably precipitated in the form 
of tricalcium phosphate (Kastle and Roberts). 2 There is also 
a precipitation of the magnesium salts (Rosenau). 3 There is a 
diminution in the amount of organic and an increase in that of 
inorganic phosphorus (Rosenau). 3 About one-third of the citric 
acid is precipitated in the form of tricalcium citrate (Pfaundler and 
Schlossmann. 4 About 90% of the carbon dioxid and 50% of the 
oxygen and nitrogen are also driven off (Pfaundler and Schloss- 
mann). 4 There is also a certain amount of decomposition of the 
compounds of casein into casein and its base. The casein is ren- 
dered less easy of coagulation by rennin and is more slowly and 
imperfectly acted on by pepsin and pancreatin (Rosenau). 3 It is 
difficult to understand why this is so, because the precipitation of 
the soluble albumins, which act as protective colloids (Alexander 
and Bullowa), 5 by boiling, should make the coagulation of the 
casein easier. The curd produced by the action of acids (Pfaundler 
and Schlossmann) 4 and rennin (Rosenau) 3 is, moreover, softer 
and more flocculent than that in raw milk. The soluble albumins 
are entirely precipitated (Sommerfeld). 6 

There are no available data as to the temperature at which the 
changes which take place in boiled milk first appear, except in the 
case of the soluble albumins. Sommerfeld 6 quotes Steward to the 
effect that heating at 149° F. (65° C.) for thirty minutes dimin- 
ishes them, and that thirty minutes at 176° F. (80° C.) completely 
destroys them. Schlossmann 7 found a slight diminution in the 
solubility of the albumins at 158° F. (69° C.) and Solomin 8 states 
that there is an "apparent" beginning of clotting of milk albumin 
by heating at 140° F. (60° C.) for fifteen minutes, but he is not 

1 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 153, 
U. S. Dept. Agric, Bureau of Animal Industry, 1910. 

2 Kastle and Roberts: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909. 

3 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 153, 
U. S. Dept. Agric, Bureau of Animal Industry, 1910. 

4 Pfaundler and Schlossmann: The Diseases of Children, 1908, i, 303. 

5 Alexander and Bullowa: Arch. Pediat., 1910, xxvii, 18. 

6 Sommerfeld: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden, 1909. 
'Schlossmann: Ztschr. f. physiol. Chem., 1896-7, xxii, 197. 

8 Solomin: Arch. f. Hyg., 1897, xxviii, 43. 



DESTRUCTION OF BACTERIA 181 

sure whether or not it is really the lactalbumin which is involved. 
It is not far wrong to conclude, therefore, with Hippius, 1 that the 
heating of milk at 149° F. (65° C.) for thirty minutes causes no 
noteworthy changes in the chemical composition of the milk. 

Ferments. — According to Hippius, 1 the proteolytic ferment of 
cow's milk is unchanged by heating for one hour at 140° F. (60° C.) 
or for one-half hour at 149° F. (65° C), but is destroyed by boil- 
ing, while the oxidizing ferment is unchanged by heating, even 
for several hours, at from 140° F. (60° C.) to 149° F. (65° C), but is 
destroyed by one hour at 169° F. (76° C). Kastle and Porch 2 
have shown, moreover, that the peroxidases are somewhat in- 
creased by heating at 140° F. (60° C). 

Bactericidal Action. — The bactericidal power of milk is still 
considerable after continued exposure to temperatures of from 
140° F. (60° C.) to 149° F. (65° C), but is destroyed by boiling 
(Hippius) 3 The alexins are affected in the same way (Von Behr- 
ing). 4 

Precipitin Reaction. — The heating of milk, even for one hour 
at 248° F. (120° C.) in the autoclave, does not diminish the precip- 
itin reaction (Hippius). 1 

Bacteria and Their Products. — It has been proved by many in- 
vestigators that the typhoid bacillus, the diphtheria bacillus, the 
dysentery bacillus and the cholera vibrio, as well as the other 
pathogenic non-spore-bearing organisms most often found in milk, 
are destroyed in milk by heating at 140° F. (60° C.) for twenty 
minutes (Rosenau) 5 and at higher temperatures for shorter lengths 
of time. Butyric acid bacteria are destroyed at from 212° F. 
to 216° F. (100° C. to 102.2° C.) for from one to two minutes 
(Sommerf eld) . 5 The spores of the peptonizing bacteria are much 
more resistant, however, some of them withstanding boiling for 
one hour (Sommerf eld) . 6 

Since the investigations of Flugge, 7 in 1894, who found spore- 
bearing peptonizing bacteria developing in milk heated at 158° F. 
(70° C.) for thirty minutes and forming highly toxic substances 
therein, it has been very generally believed that the destruction 

1 Hippius: Jahrb. f. Kinderheilk., 1905, lxi, 365. 

2 Kastle and Porch: Jour. Biol. Chem., 1908, iv, 301. 

3 Hippius: Jahrb. f. Kinderheilk., 1905, lxi, 365. 

4 Von Behring: Therap. d. Gegenw., 1904, N. F., vi, 1. 

5 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 
153, U. S. Dept. Agric, Bureau of Animal Industry, 1910. 

6 Sommerf eld: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden, 
1909. 

7 Flugge: Ztschr. f. Hyg., 1894, xvii, 272. 



182 DESTRUCTION OF BACTERIA 

of the lactic acid bacteria by pasteurization resulted in the un- 
hindered growth of undesirable, proteolytic bacteria, which pro- 
duced toxins and other poisonous products, and that pasteurized 
milk putrefied rather than soured. It has also been supposed 
that bacteria multiply more rapidly in pasteurized than in raw 
milk. Ayers and Johnson x recently found, however, that many 
acid-forming bacteria are not destroyed below 168° F. (75.6° C.) 
and that, in consequence, pasteurized milk turns sour in the same 
way as raw milk, although the process is somewhat delayed. They 
found that there were fewer peptonizing bacteria in pasteurized 
than in raw milk and that they did not multiply rapidly. The 
numerical relations of the acid-forming bacteria, the peptonizing 
(putrefactive) bacteria and the inert bacteria were practically the 
same as in clean, raw milk, and the acid development in an effi- 
ciently pasteurized milk was about the same as in clean, raw milk. 
They also found that the rate of multiplication of bacteria de- 
pended on the number of bacteria present in the milk. The rapid- 
ity of multiplication was the same in pasteurized as in raw milk 
containing the same number of bacteria and more rapid in both 
than in dirty milk. 

It is generally believed that the heating of milk, even to boiling, 
has no effect on the toxic products of bacterial growth which it 
may contain. This belief is in part justified and in part unwar- 
ranted. The true bacterial toxins are thermolabile, many of them 
being rendered inert at 140° F. (60° C). Bacterial endotoxins may 
be very resistant, however, that of the B. coli communis being, for 
example, unaffected by fifteen minutes at 272° F. (134° C.) . There 
is no doubt that the spore-bearing organisms can set up putrefac- 
tive and proteolytic changes in milk and produce poisons as the 
result. The nature of these poisons is not known. Their connec- 
tion with "milk poisoning" has been inferred, not demonstrated. 
Moreover, as far as is known, the true bacterial toxins play but 
little, if any, role in milk poisoning (Rosenau). 2 

THE EFFECTS OF THE HEATING OF MILK ON ITS DIGESTIBILITY AND ON 
ITS VALUE AS A FOOD FOR INFANTS 

Experiments in Artificial Digestion. — The evidence derived 
from artificial digestion experiments as to the comparative di- 
gestibility of boiled or sterilized and raw milk is inconclusive; there 

1 Ayers and Johnson: Bulletin 126, U. S. Dept. Agric, Bureau of Animal 
Industry. 

2 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 153, 
U. S. Dept. Agric, Bureau of Animal Industry, 1910. 






DIGESTIBILITY OF HEATED MILK 183 

is little or none as to that of pasteurized and raw milk. The 
casein is rendered less easy of coagulation by rennin, but the curd 
produced by the action of acids (Pfaundler and Schlossmann) 1 
and rennin (Rosenau) * is softer and more flocculent than that in 
raw milk. De Jager 2 concluded that raw milk was the more 
easily digested, while Fleischmann 3 decided that sterilized milk 
was more easily acted on by the digestive ferments than raw milk. 
Jemma 4 and Michael 5 found that sterilization did not impair 
the digestibility of milk. 

Animal Experiments. — Almost all experiments agree in show- 
ing that all animals do better when fed on the raw than on the 
cooked milk of their own species. Von Brunning 6 has collected 
reports of experiments of feeding animals with the raw and cooked 
milk of another animal. The results were the same in all, namely, 
that, when fed on the milk of another animal, the young animals 
did better when the milk was cooked than when it was raw. 
Raudnitz 7 fed dogs on raw and on sterilized milk and found 
that the fat and nitrogen were better utilized with the raw than 
with the sterilized milk. Lane-Claypon 8 has reviewed the lit- 
erature of this subject very carefully and done considerable ex- 
perimental work herself. She concludes from her own work that 
there is no evidence to show that, in the case of calves, boiled 
cow's milk is inferior to raw cow's milk and that, if young ani- 
mals are fed upon the milk of a suitable foreign species, they 
appear to thrive somewhat better if the milk is given boiled than 
raw. 

Experiments on Babies. — Lane-Claypon 8 has recently summed 
up the work which has been done in feeding babies on raw and 
cooked human milk and arrives at the conclusion that the data 
available are insufficient to warrant any definite decision as to the 
comparative nutritive value of raw and boiled human milk for 
babies. There is no doubt, however, that many babies thrive well 
on boiled human milk. 

Very few metabolism experiments have been done in babies as 

1 Pfaundler and Schlossmann: The Diseases of Children, 1908, i, 303. 

2 De Jager: Centralbl. f. d. med. Wissensch., 1896, xxxiv, 145. 

3 Fleischmann: Quoted by Doane and Price, Bulletin 77 of the Maryland 
Agricultural Experiment Station, 1901. 

4 Jemma: Dietet. and Hyg. Gaz., 1900, xvi, 83. 
6 Michael: Hyg. Rundschau, 1899, ix, 200. 

6 Von Brunning: Quoted by Finkelstein. See note 8. 

7 Raundnitz: Ztschr. f. physiol. Chem., 1890, xiv, 1. 

8 Lane-Claypon: Report to Local Government Board, England, N. S. 
No. 63. 



184 DIGESTIBILITY OF HEATED MILK 

to the relative utilization of raw and cooked cow's milk and these 
are incomplete and fragmentary. They show, however, little differ- 
ence in the results with the two foods. Muller and Cronheim * 
found that the calcium was less well utilized when the milk was 
cooked, but Finkelstein 2 says that their methods are open to 
criticism. Krasnogorsky, 8 on the other hand, states that the iron 
is better utilized from cooked than from raw milk. 

It has been generally believed in this country until very recently 
that babies fed continuously on cooked milk do not thrive so well 
as those fed on raw milk and that the cooking of milk predisposes 
to the development of the diseases of nutrition, while physicians in 
Europe have believed that babies thrive as well, or perhaps better, 
on cooked than on raw milk. There is, however, relatively little 
evidence on either side. Finkelstein 4 studied sixty well and 
fifty-three sick babies and concluded that there was no evident 
difference in the results with raw and with cooked milk and that 
neither the gain of the healthy nor the healing of the sick was 
visibly aided by raw milk. He quotes Czerny as having obtained 
the same results and states on the authority of an oral communica- 
tion that the experiment of feeding raw and cooked milk to a large 
series of babies had been tried for three years at the Waisenhaus in 
Stockholm and that no difference in the results from the two meth- 
ods had been noted. Variot 5 states that during the twelve years 
ending in 1904 more than 3000 infants were fed at the dispensary 
of the goutte de lait of Belleville with milk heated at 226° F. (108° 
C.) and that rachitis did not develop in any, but that anaemia was 
not uncommon. Scurvy is not mentioned. Carel 6 states that of 
210 infants belonging to the laboring class of Paris fed on raw milk, 
31.8% developed rickets, while of 373 infants of the same class fed 
on cooked milk only 15% developed rickets and none scurvy. 
Sill 7 of New York reports, on the other hand, that he found signs 
of rickets or scurvy in 97% of 179 consecutive cases of infants fed 
on pasteurized or sterilized milk. The statistics of the French 
observers are open to considerable doubt, however, because, unless 
the French infants of the hospital class are very different from the 
American, 80% of them show signs of rickets, no matter on what 
they are fed, while scurvy was not sufficiently well known in 

1 Muller and Cronheim: Therap. Monatsh., 1903, xvii, 340. 

2 Finkelstein: Therap. Monatsh., 1907, xxi, 508. 

3 Krasnogorsky: Jahrb. f. Kinderheilk., 1906, lxiv, 651. 

4 Finkelstein: Therap. Monatsh., 1907, xxi, 508. 

5 Variot: Compt. rend. Acad. d. Sc, 1904, cxxxix, 1002. 

6 Carel: Le lait sterilise, These de Paris, 1902-3. 

7 Sill: Med. Rec, New York, 1902, lxii, 1016. 



SCURVY AND HEATED MILK 185 

France at that time to be recognized unless of a most extreme type. 
Lane-Claypon l has recently studied a series of babies, part of 
whom were fed on breast-milk and part on boiled cow's milk, at 
the Municipal Infant Consultation in the Naunyn Strasse in Ber- 
lin. She found that the deficit in weight in the babies fed on 
boiled cow's milk below those fed upon the breast was not as 
much as 10% at any period. She also sums up the literature of the 
subject in her paper. 

It is very difficult to determine what influence the heating of 
milk, at whatever temperature, has on the development of rickets, 
because the exact etiology of rickets is at present so obscure. It is 
probable that heredity, improper hygienic surroundings and 
improper food all play a part in its production. It is extremely 
difficult to know in an individual case which is the most importa/r 
element and almost impossible to determine it in large serie< 
cases. Our present statistics as to the relative frequency of t c 
tis in those fed on heated and those fed on raw milk are n- 
curate enough to form the basis of any definite conclusions 
point, because they do not give any accurate data as to t 
possible etiologic conditions. 

The evidence to prove that the heating of milk prodi 
is stronger than in the case of rickets, but not at a v 
this evidence being the fact that all large series of c? 
show that a considerable proportion of the patient 
heated milk, more of them, however, on sterili 
scalded, than on pasteurized milk. It is impos 
however, that it was the heating of the milk and r 
tion of the food which caused the scurvy in th 
evident that when an individual baby is fed on 
milk it is impossible to know, if scurvy devel' 
in the special case to the heating or to the cc 
It can be only a matter of opinion. A <* 
only by the analysis of large series of cas' 
difficult, as is shown by the fact that t 
American Pediatric Society, the largf 
quoted both for and against th° e* 5 * 
of milk in the prodi 1 "*' v 
heating of milk 
in the breast- 
evidence are 

1 Lane-Clr 
No. 63. 

2 Plan* 



186 COOKING OF MILK ADVISABLE 

developed more frequently in babies fed on heated milk which 
was not used at once than on raw milk, it did not develop when 
fresh milk was heated and used at once. 

It has been asserted that the cooking of milk "devitalizes" it 
and thus renders it a less suitable food for infants. It is pre- 
sumable that what is meant by "devitalization" is the destruction 
of the ferments. The point at which this occurs has already been 
given, showing that they are not injured at temperatures below 
150° F. (65° C). There is no proof, however, that the ferments of 
milk play any part in the digestion and utilization of the milk, the 
only apparent foundation for the belief that they do being a state- 
ment of Marfan 1 in 1901 that "it is probable that the milk fer- 
ments act as stimulators and regulators of nutrition, and that they 
e identical in function with the ferments elaborated by the 
ious tissues and are intended to compensate for the deficiency 
he internal secretions of the new-born.' ' This statement is 
'ed entirely on analogies and hypotheses and not on experi- 
~>r facts. 
lg of Milk Advised as a Routine Measure. — The boiling 
sr pasteurization of milk destroys the ordinary non-spore- 
"•thogenic microorganisms. The bacterial growth in 
milk is the same as in clean, raw milk. The evidence 
ailable is insufficient to show whether cooked milk 
digestible than raw milk, whether babies thrive on it 
-aw milk and whether or not it predisposes to the 
the diseases of nutrition. Granting that the cook- 
-*s make it somewhat less digestible and that its 
^s predispose to the development of the diseases 
evident, nevertheless, that the disturbances 
'ight and insignificant in comparison with the 
^'lk contaminated with bacteria. All milk, 
uld, therefore, be cooked before being used 

'-*her the temperature at which milk is 

hanges in its composition. While it is 

Tr ^uence these changes have 

it, it is the part of 

the attainment 

of pathogenic 

ble to boiling. 

-oreover, as 

or twenty 



PASTEURIZATION 187 

minutes is efficient; lower temperatures are not. This temperature 
and time are, therefore, the ideal ones. At this temperature there 
is no change in the taste, odor or color of the milk, no noteworthy 
changes in the chemical composition are produced, the ferments 
and bactericidal action are unaffected and bacterial toxins and 
non-spore-bearing microorganisms are destroyed. 

There are three methods of commercial pasteurization in com- 
mon use: the flash method, the holding method and pasteuriza- 
tion in the bottle. The flash method consists in momentarily 
heating the milk to a temperature of approximately 170° F. (76.7° 
C.) by allowing it to flow in a film over heated metal pipes or coils 
and then at once chilling it. The holding method consists in 
heating the milk to between 140° F. (60° C.) and 155° F. (68° C.) 
and then placing the milk in a receptable where it is held at approx- 
imately this temperature for from twenty minutes to an hour. 
The flash method has been repeatedly shown to be unreliable and 
should not be employed. The holding method is not so satisfactory 
as would at first appear, because, while the destruction of the 
bacteria in a small quantity of milk by heating it at 140° F. (60° C.) 
for twenty minutes is simple enough, it is very difficult to heat a 
large volume of milk to a definite temperature and hold it at that 
temperature for a given period of time. Schorer and Rosenau * 
have shown that under ordinary commercial conditions the tem- 
peratures expected were not attained. In their four experiments, 
two planned for 140° F. (60° C.) and two for 145° F. (62.7° C.), 
from 99.4% to 99% of the bacteria were, nevertheless, destroyed. 
A certain number of pathogenic microorganisms, however, sur- 
vived. They conclude, therefore, that in order to be safe, pasteur- 
ization under commercial conditions should be at 145° F. (62.7° C.) 
for from thirty to forty-five minutes. Schorer 2 further concludes 
that the safest method for pasteurization is in the sealed bottle, 
allowing at least thirty minutes for heating to the temperature 
of pasteurization and then pasteurizing at 145° F. (62.7° C.) for 
thirty minutes. He also wisely advises that all commercial pasteur- 
ization shall be carried out under official supervision. 

It must never be forgotten that the pasteurization of milk does 
not do away with the necessity of taking care of it and keeping it 
cold. It is just as important to keep pasteurized milk cold as it is 
to keep raw milk cold, because pasteurization simple diminishes 
the number of microorganisms. It does not destroy them entirely. 

While it is easier to approach laboratory methods in the home 

1 Schorer and Rosenau: Jour. Med. Res., 1912, xxvi, 127. 
2 Schorer: Am. Jour. Dis. Child., 1912, iii, 226. 



188 PASTEURIZATION 

than under commercial conditions, it is wiser to adopt 145° F. 
(62.7° C.) for thirty minutes as the standard instead of 140° F. 
(60° C.) for twenty minutes, in order to be sure that the pasteur- 
ization is efficient. The changes produced in the milk at this 
temperature and time are little, if any, greater than at the lower 
temperature and shorter time. 

It is not necessary to have any special apparatus for the pasteur- 
ization of milk in the home, as any dish of sufficient size and depth 
will do. Each feeding should be placed in a separate, clean, boiled 
bottle. The bottle should then be tightly stoppered with non- 
absorbent cotton and placed in a pail or dish of cold water, the 
water in the dish being at the level of the milk in the bottle. The 
dish should then be placed on the stove and heated until the ther- 
mometer, suspended in the water, reaches 145° F. (62.7° C). The 
dish and its contents should then be taken off the stove and covered 
with a blanket. It should be allowed to stand for thirty min- 
utes. The bottles should then be taken out, cooled quickly, 
preferably in running water, and kept in a cold place until used. 

There are several pasteurizers on the market, designed for home 
use, which are more convenient, although no more efficient. That 
sold by the Walker-Gordon Laboratory is a good one. Another, 
designed by Dr. R. G. Freeman of New York, although working 
on a little different principle, is very satisfactory. 

Sterilization by electricity is carried on in bulk in the plant 
of the Liverpool Corporation Milk Depot. All bacteria of the 
bacillus coli group, those bacteria which sour milk, probably the 
streptococci and bacillus of tuberculosis are said to be destroyed 
by the use of 2.2 amperes at 3900 to 4200 volts for two to three 
seconds. The temperature reached by the milk is 64° F. 1 

»Beattie: Jour. State Med. 1916, xxiv 97. 



CHAPTER XVI 
CERTIFIED MILK 

Certified milk is the product of dairies operated in accordance 
with accepted rules and regulations formulated by authorized 
medical milk commissions to insure its purity and adaptability 
for infants and invalids. The methods and standards for the 
production and distribution of certified milk adopted by the Amer- 
ican Association of Medical Milk Commissions, May 1, 1912, are 
in brief as follows: 

The surroundings of all buildings shall be kept clean and free 
from accumulations of dirt of all sorts, and the stable yards shall be 
well drained. The pastures shall be free from marshes, stagnant 
pools or streams which may be contaminated. The buildings shall 
be so located as to afford proper shelter and drainage and relative 
freedom from dust. The stables shall be so constructed as to 
facilitate the prompt and easy removal of waste products. The 
floors shall be of non-absorbent material and the gutters of cement. 
All interior construction shall be smooth and tight. The drinking 
and feed troughs shall be cleaned daily. The stanchions shall be 
provided with throat latches. The stables must be provided with 
adequate ventilation, each cow having at least 600 cubic feet of air 
space, with 2 ft square of window area for each 600 cubic feet of 
air space. Flies, vermin and other animals shall be excluded from 
the buildings. The bedding must be clean and dry. The soiled 
bedding and manure shall be removed at least twice daily. Man- 
ure shall not be even temporarily stored within 300 feet of the 
barn or dairy building. Cleaning of the barn shall be done at 
least an hour before milking time. The cows shall be groomed 
daily, and the hairs about the udder and tail clipped short. The 
udders and teats shall be cleaned, washed with a cloth and water 
and wiped dry with another clean sterilized cloth, before milking. 
Food-stuffs shall be brought into the barn only immediately be- 
fore the feeding hour, which shall follow the milking. The food 
shall be suitable and well balanced. The cows must have at least 
two hours out of door exercise daily in suitable weather. The 
hands of the milkers shall be washed throughly and dried before 
beginning milking and before the milking of each cow. Clean 

189 



190 CERTIFIED MILK 

outside clothes and a cap shall be worn during milking, these to 
be washed or sterilized each day. The fore-milk shall be rejected. 
The milk of all cows shall be excluded for a period of forty-five 
days before and seven days after parturition. The milk shall be 
taken immediately to a clean room and emptied through strainers 
of cheesecloth or absorbent cotton into a can. 

The dairy building shall be located at a suitable distance from 
the stable and dwelling and there shall be no hogpen, privy or 
manure pile at a higher level or within 300 feet of it. The dairy 
building shall be kept clean and shall not be used for purposes 
other than the handling and storing of milk and milk utensils. 
It shall be well lighted, screened and drained. 

The temperature of the milk shall be immediately reduced to 
45° F. and maintained at a temperature between 35° F. and 45° F. 
until delivery to the consumer. The bottles shall be properly 
sealed, the seal to include a sterile hood which completely covers 
the Up of the bottle. The bottles shall be properly cleaned and 
sterilized. The milk pails shall be properly made and preferably 
have an elliptical opening 5 by 7 inches in diameter. The water 
supply shall be free from contamination. Proper toilet facilities 
shall be provided for the milkers outside the stable and milk house. 

The milk packages must be kept free from dust and dirt during 
transportation. No bottles shall be collected from houses in which 
there is a communicable disease. All certified milk shall reach the 
consumer within thirty hours after milking. 

The herd shall be free from tuberculosis, as shown by the proper 
application of the tuberculin test by the veterinarian of the com- 
mission. The test shall be applied at least annually. All cows 
shall be properly registered. Cows sick with other diseases than 
tuberculosis shall be isolated and their milk destroyed until the 
cows are restored to the herd by the veterinarian. 

Certified milk shall contain less than 10,000 bacteria per cubic 
centimeter when delivered. Bacterial counts shall be made at 
least once a week. 

The fat standard for certified milk shall be 4%, with a permis- 
sible range of variation of from 3.5% to 4.5%. Higher fat per- 
centages for milk or cream may, however, be certified. The fat 
content shall be determined at least once a month. 

The protein standard shall be 3.50%, with a permissible range 
of variation of from 3% to 4%. The milk shall be free from adul- 
teration and coloring matter, and preservatives shall not be added 
thereto. The milk shall not be subjected to heat unless especially 
directed by the commission to meet emergencies. The specific 



CERTIFIED MILK 191 

gravity shall range from 1.029 to 1.034. It shall be determined 
at least once a month. 

No person shall be employed in the production or handling of 
milk until he has been found healthy by the attending physician. 
No person shall be employed who has been recently associated with 
children sick with contagious diseases. Suitable dormitories and 
bathing facilities shall be provided for the employees and they 
shall be required to use them. If a contagious disease develops 
among the employees, the employees shall be quarantined, the 
premises fumigated and the milk pasteurized as long as the com- 
mission thinks necessary. The commission shall have power to act 
as its judgment dictates when contagious diseases are present. 

It is possible to produce a reasonably clean milk without ful- 
filling all the requirements of the American Association of Medical 
Milk Commissions for the production of certified milk. It is 
possible to do this, moreover, without increasing materially the 
cost of the production of the milk. The milkers and those who 
handle the milk must, of course, be clean. So also must be the 
utensils which are used. The barns can easily be so arranged as to 
be reasonably free from dust and dirt. Experience has shown that 
the contamination of the milk is much less when the cows are milked 
out of doors than when they are milked indoors. If the cows are 
milked indoors certain precautions should be taken to avoid filling 
the air with dust. No dry feed should be given at or just before 
the time of the milking and the floors should not be scraped or 
cleaned just before milking. The cows should not be dry brushed 
before milking. The flanks and udders may be wiped instead of 
washed before the milking. This is nearly as effectual and much 
less expensive. A covered milk pail should always be used as it 
diminishes the contamination at least 50%. 



CHAPTER XVII 
GENERAL PRINCIPLES OF ARTIFICIAL FEEDING 

In approaching the subject of artificial feeding it must be remem- 
bered that there are only a few food elements. A baby's food may 
contain all of these elements, it must contain some of them, it 
cannot contain any other elements. These food elements are fat, 
carbohydrates, protein and salts. The carbohydrates comprise 
the sugars and starches. 

It must also be remembered that a baby, in order to thrive and 
gain, must have a sufficient amount of food. The amount of food 
is not calculated, however, in ounces or pints of food, but in food 
values, or calories. A baby must receive a sufficient number of 
calories in proportion to its body weight. Otherwise, it cannot 
gain. It is not sufficient, however, for a food to contain a sufficient 
number of calories; it must also contain a sufficient amount of 
protein to cover the nitrogenous needs of the baby. A baby will 
eventually die while taking a food high in calories but too low in 
protein. 

It must further be remembered that a food may contain a 
sufficient number of calories and a sufficient amount of protein to 
cover the caloric and protein needs of the baby and yet not be a 
suitable food for any baby, or, if suitable for one baby, not for 
another. It is absolutely necessary to fit the food to the digestive 
capacity of the individual infant. Otherwise it will cause disturb- 
ance of the digestion and the baby will not thrive. 

These fundamental principles must always be borne in mind in 
feeding babies artificially. If a single one of them is forgotten, the 
results will be failure rather than success. 

It would seem at first glance as if an artificial food, which con- 
tained the same food elements in the same relative proportions 
that they are in human milk, would be a perfect food and answer 
as well as human milk. It has been shown, however, that, while 
some babies will thrive on a food of this composition, it is not 
suitable for all babies or for all ages. While babies thrive through- 
out the nursing period on human milk of uniform strength, they 
cannot take a food as strong as this in the early weeks and months, 
and need a stronger food in the latter months. It is a fact, more- 

192 



BREAST MILK NOT IMITATED 193 

over, that no artificial food, although it may contain the same 
proportions of the different food elements, is the same as human 
milk. It is impossible, as will be shown later, to make an artificial 
food in any way which is identical with human milk. 

The composition of human milk does, however, teach us certain 
things as to the digestive capacity of infants and as to the general 
principles to be followed in the preparation of a food to meet this 
digestive capacity. Nature provides a dilute food rich in fat and 
carbohydrates and relatively low in protein, that is, rich in heat- 
producing substances and relatively low in tissue-building sub- 
stances. It seems reasonable to suppose that this type of food is 
the one best suited for the infant's digestive power and metabolic 
processes. Well babies should, therefore, be given dilute foods 
which contain relatively large amounts of fat and carbohydrates 
and relatively small amounts of protein. The object in giving 
babies such foods is, however, not to imitate the composition of 
breast-milk but to follow Nature's indications as to the infant's 
digestive capacity and metabolic processes. Well babies, as al- 
ready stated, on the whole thrive better on foods of this char- 
acter than on any others. The same principles cannot, however, 
be applied to the feeding of sick babies or to that of a certain 
number of well babies. When a baby does not thrive on foods of 
this type, they must be discarded at once and the composition of 
the food regulated to fit the digestive capacity of the individual 
baby. This digestive capacity must be determined by a careful 
study of the symptoms and of the stools in the individual case. 
The composition of the food must then be varied to suit the in- 
dividual baby. Success in the artificial feeding of infants can 
never be attained by following any hard and fast rules. Every 
baby is a problem by itself. The baby, not rules, must be followed 
to solve this problem. 

The artificial food for a baby is best prepared from the milk of 
some animal for the following reasons: The milk of animals con- 
tains the same food elements which are present in human milk. 
It does not contain any other elements. It is intended for the 
growth and development of a young animal. No other food has 
these same characteristics. It must be remembered, however, that 
the milk of an animal is fitted to the digestive capacity and in- 
tended for the growth and development of the young of that 
animal and not for the human infant. It is, therefore, not entirely 
suitable for a baby, and, while some babies will thrive on the un- 
diluted milk of an animal, in most instances it has to be modified 
in some way to be suitable for a baby. 



194 IDIOSYNCRASY TO COW'S MILK 

The milk of the cow is the one most suitable for the preparation 
of a baby's food. The milk of the mare, it is true, resembles more 
closely in its composition that of human milk than does cow's milk. 
Its use as a food for babies is, however, not feasible, because of its 
rarity and the difficulty in obtaining it. The milk of the goat, 
which is claimed by some authorities to be better than cow's 
milk as a food for babies, is very much like cow's milk in its com- 
position. It has to be modified to fit the digestion of the average 
baby in the same way as cow's milk. Cow's milk is easy to obtain 
in any amount, in almost any place. It is difficult to obtain goat's 
milk in large amounts, and then only in a few places. There is, 
therefore, no reason for preferring goat's milk to cow's milk. The 
reasons that goat's milk has been considered better than cow's 
milk for the feeding of infants are probably because goat's milk 
was given to the babies when it was fresh and cow's milk when 
it was old, and because in the countries where goat's milk was used 
most freely the cows were tubercular and the goats, on account 
of their resistance to infection with tuberculosis, were not. At 
the present time when so much is known about infant feeding, 
these reasons are not applicable. Pure milk can now be obtained 
by anyone who will take the trouble to get it, and anyone who 
does not take the trouble to find out whether the milk which is 
given to a baby comes from tuberculin tested cows or not, de- 
serves to have tuberculosis develop in the babies. 

Idiosyncrasy to Cow's Milk. — It is often said that certain 
babies cannot take cow's milk in any form and that they must be 
fed, therefore, in some other way. In most of these cases the 
trouble is not with cow's milk but with the way in which it has 
been given. Almost all of these babies can take cow's milk per- 
fectly well if it is properly modified to fit their individual digestive 
capacities. In rare instances, however, cow's milk does cause 
serious disturbances in whatever form it is given, whether as 
cream, skimmed milk, whey or condensed milk. In such cases even 
a very small amount will cause trouble. In these instances the 
symptoms are manifestations of anaphylaxis to the protein of cow's 
milk. If a skin test to cow casein is performed, a positive re- 
action is obtained in the majority of instances. Such a positive 
reaction establishes the diagnosis of idiosyncracy to cow's milk. 
There is often a family history of anaphylaxis to some foreign 
protein. It will almost always be found that these babies were 
given cow's milk in the first few days of life at a time when the 
intestines were in an abnormal condition. The foreign protein 
of the cow's milk was probably absorbed at that time and pro- 



MODIFIED MILK 195 

duced the sensitization. In a few instances an idiosyncracy devel- 
ops in later infancy, especially when the cow's milk is given for the 
first time at intervals of ten days or more, thus sensitizing the 
infant in a similar manner to experimental sensitization in animals. 
Such babies have to be given either breast-milk or goat's milk 
until they are old enough to take other foods than milk. They 
may, however, be desensitized by giving them minute doses of 
cow's milk, gradually increasing the amount until immunity is 
obtained. This procedure as a rule is unnecessary because the 
idiosyncrasy is usually outgrown during early childhood. 

Modified Milk. — The composition of human milk and cow's 
milk has already been given. They are roughly as follows; 

TABLE 38 

Human milk Cow's milk 

Fat 4.00% 4.00% 

Sugar 7.00% 4.75% 

Protein 1.50% 3.50% 

Salts 0.20% 0.70% 

Both are amphoteric in reaction when they leave the breast. 
Cow's milk is usually acid when it reaches the baby. Human 
milk is practically sterile as the baby takes it. Cow's milk, even 
under the best conditions, is far from sterile when the baby gets it. 
The emulsion of the fat is much finer in human milk than in cow's 
milk. The proportion of fatty acids is much higher in cow's milk 
than in human milk. A large proportion of the protein in human 
milk is in the form of whey protein. A large proportion of the 
protein in cow's milk is in the form of casein. Human milk is not 
coagulated by commercial rennin, cow's milk is coagulated. Both 
are coagulated by human rennin. The enzymes of the two milks 
are different and each milk has a specific serum reaction. 

It is evident, therefore, that no matter how cow's milk is mod- 
ified, it will still be different from human milk. The percentages 
of the different food elements can be made the same. The differ- 
ence in the protein can be corrected by the use of whey. The 
emulsion and the composition of the fat will, however, always be 
different. The ferments can never be made the same and the 
specific serum reaction cannot be changed. It is also evident that 
cow's milk must be modified in some way in order that the different 
food elements may be in the same relations in the food that they 
are in human milk. 

Pure Milk. — The milk from which a baby's food is prepared 
must be pure. It is impossible to make a proper food for a baby 



196 BREEDS OF COWS 

from impure and dirty milk, no matter how much it is modified or 
how much care is taken in its preparation. The requisites of a 
pure milk have already been described. 

Breeds of Cows. — It also makes a difference from what breed 
of cows the milk comes. The milk of Ayreshires and Holsteins is 
much more suitable than that of Jerseys and Guernseys, because 
of the lesser fat content, the finer division of the fat and the lower 
proportion of volatile fatty acids. The milk of the former breeds 
should, therefore, be always employed, if possible. Some babies 
can take Jersey milk without being disturbed, other babies cannot.. 
It will be found in many instances that babies can take the same 
amount of fat in mixtures made from the milk of Holstein and 
Ayreshire cows without derangement of digestion, while there is 
serious disturbance when the milk comes from Jerseys or Guern- 
seys. 

Mixed Milk versus the Milk of One Cow. — It is far better, other 
things being equal, to use the mixed milk of a herd in preparing a 
baby's food than the milk of one cow, because if the milk comes 
from one cow and the cow is ill in any way, the baby is almost 
certain to be disturbed, whereas if one or two cows in a herd are 
ill, the milk from these cows will be so diluted that the baby will 
probably not notice it. On the other hand, it is, or should be, 
self-evident that the milk of a healthy cow properly fed and 
properly cared for, taken in the proper way, and kept under proper 
conditions, is better than the mixed milk of a herd which is im- 
properly fed and whose milk is not carefully obtained or carefully 
taken care of. 

GENERAL PRINCIPLES OF THE MODIFICATION OF MILK 

It is evident, when the composition of human milk and cow's 
milk is compared, that, while the percentage of fat is the same in 
the two milks, the percentage of sugar is higher and that of the 
protein lower in human than in cow's milk. It is necessary, in 
order to have foods prepared from cow's milk correspond in the 
general relations of the fat, sugar and protein to each other to 
those in human milk and, therefore, to meet the indications for a 
food suitable for the average well baby, to modify these relations in 
some way. Simple dilution of cow's milk does not change these 
relations at all. Simple dilutions of whole milk do not, therefore, 
provide a suitable food for the average well baby. 

It is a fact that when milk stands the fat rises to the top, while 
the sugar and protein remain approximately evenly divided 
throughout the mixture. This fact of the unequal division of the 



PRINCIPLES OF MILK MODIFICATION 197 

fat and the comparatively equal division of the sugar and protein 
is also true when milk is separated by machinery. The cream 
contains a relatively large amount of fat and a relatively small 
amount of sugar and protein, when compared with whole milk. 

Cream is technically any milk which contains more than 4% of 
fat. The composition of different creams is as follows : 

TABLE 39 





Fat 


Sugar 


Protein 


10% cream 


10% 

16% 
32% 


4.45% 
4.20% 
3.40% 


3.27% 
3.05% 


16% " 


32% " 


2.50% 







It is evident that when cream is diluted the relation between the 
fat and the protein will be similar to that in human milk. For 
example, a mixture of one part of 16% cream with three parts of 
water will contain 4% of fat and about 0.75% of protein, while a 
mixture of one part of 10% cream with three parts of water will 
contain 2.50% of fat and approximately 0.80% of protein. It is 
very easy to raise the percentage of sugar, in order to get a rela- 
tively high sugar content, by the addition of dry milk sugar. The 
modification of cow's milk to fulfill the indications given by Nature 
as to the average infant's digestive capacity consists roughly, 
therefore, in the dilution of cream with water and the addition of 
dry milk sugar. 

If the modifications of milk prepared on these general principles 
do not fit the individual baby, it is easy to increase the percentage 
of protein in relation to the percentage of fat by the addition of 
skimmed or fat-free milk, which contain a considerable amont of 
protein and very little fat. If the casein is not easily digested, it is 
easy by the use of whey in the mixture to replace a part of it by 
whey protein. If it is desired to give a baby starch in its food, 
starch can be added in the form of a cereal water. If it is desired, 
for any reason, to change the character of the sugar, another sugar 
may be added in place of milk sugar. In these ways all possible 
modifications of cow's milk may be obtained and the needs of the 
individual baby met. 

FEEDING IN PERCENTAGES 

The most satisfactory way of determining the composition of an 
infant's food is by thinking and calculating in percentages of the 
different elements of the food. Percentage feeding, so-called, is not 



198 FEEDING, IN PERCENTAGES 

a method of feeding. It is merely a method of calculation and a 
means of attaining relative accuracy in the preparation of infants' 
foods. It neither presupposes nor implies anything as to what 
should be in the food or why it should be there. These points must 
be determined in other ways. Accuracy is as important in the 
calculation and writing of a prescription for a baby's food as in that 
for a medicine. In no other way are such accurate results obtained 
as by the percentage method. It must not be supposed, however, 
that the mixtures, when prepared, contain exactly the percentages 
of the food elements which they are calculated to contain. This 
would be an impossibility, because the cream, milk and so on of 
which they are made are not constant in their composition. This 
is especially true when the mixtures are prepared at home. The 
percentages are, however, approximately correct and nearly enough 
so for practical purposes. Fortunately most babies do not notice 
slight variations in the composition of the food. In fact, the varia- 
tions in the composition of a mixture from day to day are probably 
less than the daily variations in the composition of a breast-milk. 
In any event, the relative proportions of the various food elements 
are correct, even if the exact percentages are not. If the food does 
not agree, changes in the percentages to meet the indications 
furnished by the symptoms will be accurate relatively to the 
original percentages, which is all that is necessary. 

USE OF CALORIES IN INFANT FEEDING 

The calorie referred to in infant feeding is the large calorie, that 
is, the amount of heat necessary to raise one kilogram of water 
1° C. A baby cannot thrive and gain unless its food contains a 
sufficient number of calories in a form which can be utilized by the 
baby. In general, babies require from 100 to 120 calories per 
kilogram of body weight during the first six months in order to 
gain, and in the neighborhood of 100 calories during the rest of the 
first year. Ninety calories per kilogram is usually sufficient during 
the second year. Most young babies will just about hold their 
weight on 70 calories per kilogram, a few will gain regularly on this 
amount while other babies need as much as 140 calories per kilo- 
gram in order to gain. Babies that have been underfed or that are 
convalescing from a severe illness, whether acute or chronic, need 
more calories than do normal babies. Babies that are fatter than 
the average baby will gain on fewer calories than will the average 
baby. The fatter the baby is, the fewer calories he needs, a very fat 
baby often needing only 90 calories per kilogram. Conversely, the 



CALORIES 199 

thinner or more atrophic a baby is, the more calories it needs, many 
extremely emaciated babies requiring as much as 160 calories per 
kilogram. Another factor which modifies the caloric need of an 
infant is its muscular activity. The quieter a baby is, the less 
food it requires, and vice versa. That is to say, there is no hard 
and fast rule as to how many calories a given baby must have in 
order to gain. The calculation of the caloric value of the food 
will show whether the failure to gain is due to an insufficient 
amount of food or to some other cause. On the other hand, if a 
baby has a disturbance of the digestion on a food which seems 
suitable for it, the calculation of the caloric value of the food will 
show whether the disturbance is due to overfeeding or not. It must 
be remembered, however, that while the caloric value of a food 
may be high, the food may be valueless to the baby, because it 
cannot utilize it. Cheese and crackers both have a high caloric 
value, but they are not suitable articles of diet for a three months' 
old baby. A food the caloric value of which is high and the com- 
position of which is suitable for the average baby may in like 
manner be of but little value in a given case. For example, if a 
baby with an intolerance for fat is given a food whose caloric 
value is correct but which is due in considerable part to its fat 
content, it will not only not gain on this food but will be made ill. 
On the other hand, if the caloric value is due to the presence of 
sugar and protein, it would be able to utilize them and gain. 
Chapin has recently shown, moreover, that on account of the 
different powers of fat and carbohydrates as producers of meta- 
bolic water, they cannot be considered as interchangeable as 
regards favoring the growth of the organism. He has also called 
attention to the fact that the net caloric value of a food depends on 
the amount of energy required for its digestion and assimilation. 
Foods having the same gross caloric value may differ very mate- 
rially, therefore, in their net caloric value. 1 It has also been 
shown many times that the caloric needs of an individual, whether 
baby or adult, depend very largely on the amount of exertion 
which the individual makes, the need of food for the produc- 
tion of energy depending on exertion. It is evident, therefore, 
that a quiet baby which sleeps all day requires much less food 
energy than an active, restless baby, or one which cries most of 
the day. 

It is evidently irrational, therefore, to base any scheme or system 
of feeding on the caloric needs of babies or on the caloric values 
of food. The calculation of the calories in a given food can 
1 Chapin: New York Medical Journal, 1913, xcvii, 269. 



200 FEEDING INTERVALS 

serve merely as a check. Used in this way it is often of great 
value. 

Intervals in Artificial Feeding. — While, as already stated, 
babies that are nursed do much better on the whole when they are 
fed at regular intervals, many of them get along fairly satisfac- 
torily and some of them thrive perfectly well, even if fed at any 
and all times. This is not the case with artificially-fed babies. 
They are almost certain to be upset and suffer from disturbances of 
digestion, unless they are fed at regular intervals. Regularity is 
not only advisable with them, as with the breast-fed baby, but 
necessary. In general, the intervals are the same for the artificially 
fed as for the breast-fed. It is impossible and irrational, however, 
to lay down any arbitrary rules as to the intervals between feedings 
at different ages. They must vary with the amount of food given 
at a feeding, the strength of the food and its composition, as well 
as with the digestive capacity and gastric motility of the individual 
infant. It is evident that if a large amount is given at a feeding, 
the intervals between feedings must be longer than when a small 
amount is given, as the time required for the stomach to empty 
itself will be longer. The time required for the stomach to pass on 
a food rich in fat is greater than that required to pass on one poor in 
fat, because fat delays the emptying of the stomach. A mixture in 
which the protein is largely in the form of whey protein will leave 
the stomach more quickly than one in which the protein is almost 
entirely casein. Foods rich in carbohydrates and low in fat and 
protein leave the stomach quickly. There is no doubt that the 
digestive capacity and gastric motility is different in different 
infants. It is evident, therefore, that the intervals must be deter- 
mined in each case on the conditions actually present in that case, 
not by any set rules. 

Amount of Food at Single Feeding. — When a baby is nursed, 
Nature, under normal conditions, regulates the supply to the 
demand and there is no danger of overfeeding. There is no such 
natural relation, however, between what the person in charge of a 
baby may think it requires and its actual needs. A breast-fed 
baby, while it will take practically the same amount of milk from 
day to day, does not take the same amount at each feeding. It will, 
in fact, often take three or four times as much at one feeding as it 
does at the next without suffering any disturbance of the digestion. 
It has been found, however, that it is not safe to let a baby take all 
that he will at each feeding from an unlimited supply of artificial 
food. If this method is followed, indigestion almost invariably 
results. In order to avoid trouble, the baby must be given the 



, 



AMOUNT OF FOOD 201 

same amount at each feeding. This amount is the maximum which 
is proper for the given baby. It is not necessary, however, that 
the baby always takes the whole of it. 

It is very difficult, indeed, to know just how much food a baby 
should take at a feeding. It depends not only on the age, but 
also upon the size of the individual baby. Some babies, moreover, 
require more food than other babies of the same age and weight. 
The amount of food given at a feeding must depend also on the 
intervals between feedings. It is self-evident that, the twenty- 
four hour amount being the same, more food must be given at a 
feeding when the intervals are long than when they are short. The 
amount of food to be given in 24 hours is the most important point 
to be determined. When this is decided, it must be divided equally 
according to the number of feedings to be given. If the twenty- 
four hour amount is correct, the amount given at a feeding and the 
number of feedings are, within reasonable limits, relatively un- 
important. The figures as to the gastric capacity at different ages 
are of comparatively little value because of the difficulties and 
inaccuracies inherent to the various methods of determining them. 
Even if these figures were correct, they would not be of great value, 
because of the fact that more or less of the food ingested passes 
from the stomach into the duodenum while it is being taken. How 
much passes varies undoubedly in different babies and in the same 
baby at different times. 

Experience has shown that the amount of food taken in twenty- 
four hours increases rapidly during the first three months and less 
rapidly during the remainder of the first year. The average baby 
takes ten or twelve ounces at the end of the first week, twenty 
ounces when a month old and thirty-two ounces when four months 
old. It will take thirty-six to forty ounces at six months and forty- 
eight ounces at nine months. 

It is evidently impossible, therefore, to give any absolute figures 
as to how much food should be given a baby of a certain age. In 
a general way, however, the average baby takes about one-half 
ounce at a feeding in the first few days, and an ounce to an ounce 
and a half when it is a week or ten days old. It takes about two 
and one-half ounces when it is a month old, four ounces at three 
months, six ounces at six months and eight ounces at nine months. 
It is, as already stated, impossible to lay down any hard and fast 
rules as to the intervals between feedings and the amount to be 
given at a single feeding at given ages. The intervals and the 
amount at each feeding must vary with the circumstances in the 
individual case. While this is true, it is, nevertheless, possible to 



202 



FEEDING INTERVALS 



give certain figures, founded on what average babies have been 
found by experience to have done in the past, as to what the 
average baby may be expected to do. These figures must not be 
followed blindly, but can serve as a guide as to what may be 
expected of an average baby of a given age. 

TABLE 40 



Age 



1 week. 
4 weeks 

4 mos . . 
6 mos . . 
9 mos . . 



24-hour amount 



10-12 oz. 
20 oz. 

32 oz. 
36-40 oz. 

48 oz. 



Number of feedings, amount and 
intervals 



10 feedings of 1 oz. at 2 hr. intervals 



lHoz. 23^ hr. 

2Y 2 oz. 2V 2 hr. " 
3 oz. 3 hr. 

4^ oz. 3 hr. 

6 or 6K oz. 3 hr. " 

8 oz. 3 hr. " 
9% oz. 3 or 4 hr. " 



Ten feedings at two-hour intervals means every two hours from 
6 A. M. to 10 P. M. and once between ten and six at night. 

Eight feedings at two and one-half hour intervals means every 
two and one-half hours from 6 A. M. to 9 P. M. or 10 P. M., and 
once between the evening feeding and morning. 

Seven feedings at three-hour intervals means every three hours 
from 6 A. M. to 10 P. M., and once between ten and six at night. 

Six feedings at three-hour intervals means every three hours 
from 6 A. M. to 9 or 10 P. M. 

Five feedings at three-hour intervals means every three hours 
from 6 A. M. to 9 P. M. 

Five feedings at four-hour intervals means every four hours from 
6 A. M. to 10 P. M. 

The night feeding may be omitted, in many instances, before the 
baby is six months old. If so, the amount which was in this 
bottle must be distributed among the other bottles in order to keep 
the twenty-four hour amount the same. 

Composition of Food at Different Ages. — It is impossible to 
over-emphasize the facts that babies cannot be fed by rule and 
that the food of each baby must be adapted to the digestive 
capacity of that individual baby. It is equally true, however, that 
young infants cannot take as strong an artificial food as older 
babies and that the average well baby thrives better on artificial 
foods in which the relation of the fat, sugar and protein in the 






COMPOSITION OF FOOD 



203 



mixture are similar to those in human milk. Experience in the 
feeding of large numbers of well babies has shown that, on the 
average, babies of certain ages take, digest and thrive best on 
certain strengths of food. The expert in the feeding of infants has 
no need of tables showing the average strength of food taken at 
different ages. He is able to judge very closely from the age, 
appearance and past history of the baby what food is suitable for 
it. These of less experience, however, need such a table to serve as 
a guide in the preparation of the first mixture for a well baby when 
it comes into their hands, and to show them in a general way what 
the average well baby may be expected to take. In any hands, the 
first formula must always be something of an experiment. After 
this, the food must be prepared to meet the indications furnished 
by the symptoms, the findings in the stools, the appearance and the 
weight chart of the individual baby at the given time. 

TABLE 41 
Composition op Food for Average Well Babies 



Age 


Fat 


Sugar 


Protein 


First food 


1.00 
2.00 
3.00 
3.50 
4.00 
4.00 
4.00 


5.00 
6.00 
7.00 
7.00 
7.00 
7.00 
7.00 


0.50 


First week 


0.75 


1 month 


1.00 


2 months 


1.50 


4 months 


1.75 


6 months 


2.25 


8 months 


2.50 







Variation of Different Food Elements. — It is possible not only 
to vary the percentages of the different elements in the food, 
but also to use these elements in different forms. There are, for 
example, several varieties of sugar, one of which will agree in one 
condition, another in another. Barley starch may be used in one 
instance, oat starch in another. Whey protein may be given 
instead of casein when the latter causes disturbance, or the casein 
may be partially digested by pancreatization. Alkalies may be 
added to the food or lactic acid organisms may be grown in it, and 
so on. 

Fat. — The amount of fat in the food may be varied, but the 
character of the fat cannot be changed, except in so far as it differs 
in the milk of different breeds of cows. The emulsion of the fat 
may be made much more complete, however, by means of the 
process known as "homogenization," by which the fat droplets 



204 FAT 

are rendered extremely small. Other fats, such as olive oil, may 
also be introduced into the milk by this process. 1 It has been 
thought by some physicians that the cream obtained by centrifu- 
galization is less suitable for the preparation of foods for infants 
than that obtained by gravity. There is, however, no proof that 
this is so, and the general experience is that it makes no difference 
whether the cream is obtained by gravity or centrifugalization. 
The upper layers of cream which has risen contain many more 
bacteria than the lower. It is of certain advantage, therefore, to 
remove the upper two ounces of cream from each quart in order to 
reduce the bacterial contamination. 2 

Very few babies are able to take more than 4% of fat in their 
food continuously without developing disturbances of digestion or 
of nutrition. More than 4% of fat should, therefore, never be 
given, except for special indications, and, if it is so given, it should 
not be kept up for any length of time. Most well babies over three 
months old can take 4% of fat without any trouble resulting. 
Indeed, in most instances they thrive better on this amount than 
on lower percentages. This is not the case with sick babies, how- 
ever, and here, as always, it must never be forgotten that con- 
clusions as to what is a suitable food for a sick baby cannot be 
drawn from what is suitable for a well one. It is safer when babies 
are fed on modifications of milk prepared at home not to give more 
than 33^%, or even more than 3% of fat, because, as in most 
methods of calculation the fat content of the skimmed milk is 
disregarded, the foods always contain more fat than they are 
supposed to. 

One of the reasons why too high precentages of fat are given is 
the desire to make the baby gain in weight. Mothers are always 
and physicians not infrequently inclined to attach too much im- 
portance to the weight chart and, believing that fat tends to 
increase the weight more than anything else, to increase it unduly 
on this account. As a matter of fact, the fat baby is often not 
as strong and vigorous as the thinner baby, and fat in the food is 
no more useful than carbohydrates in increasing weight. 

Another reason why babies are given excessive amounts of fat is 
that most mothers and nurses, and unfortunately many physicians, 
think that fat always has a laxative action. They, therefore, in- 
crease the amount of fat in the food whenever a baby is con- 
stipated, not realizing that an excessive amount of fat is one of 
the most common causes of constipation in infancy. Increasing 

1 Ladd: Archives of Pediatrics, 1915, xxxii, 409. 

2 Hess: Journal A. M. A. 1909, liii, 523. 



SUGARS 205 

the percentage of fat in the food in such cases, of course, merely 
makes a bad matter worse. 

The chief reason why babies get excessive amounts of fat in their 
food is that physicians do not appreciate the fact that cream and 
top milk are indefinite terms or that, if they do appreciate this fact 
and are careful in their calculations, they are not precise enough in 
their directions as to the preparation of the food. If 32% cream is 
used in the preparation of a milk mixture, the formula for which 
was calculated on the basis of 16% cream, it is evident that the 
mixture will contain twice as much fat as was intended. In the 
same way, if a top milk mixture is made with a certain number of 
ounces from the top eight ounces instead of with the same number 
of ounces from the top sixteen ounces as ordered, it will contain 
nearly twice as much fat as it should, the fat content of the top 
eight ounces being 13.3% and that of the top sixteen ounces, 7%. 
The physician must always decide what percentage cream or what 
top milk he will use in the preparation of his mixture, and then 
calculate the amount to be used on the basis of its fat content. 
Otherwise, the fat content of the food will never be what he thinks 
it is. He must also give the person who is to prepare the food such 
explicit directions as to how to obtain the cream or top milk that 
she cannot possibly make a mistake. 

It must be remembered on the other hand, however, that the 
caloric value of fat is more than twice as great as that of the 
carbohydrates and protein. Unless a reasonable amount of fat is 
used in the food, it is, therefore, often difficult to meet the caloric 
needs without unduly increasing the quantity of the food. 

Sugars. — Milk sugar being the only form of sugar present 
in human milk and in the milk of animals, it seems -reasonable to 
suppose that it is the sugar most suitable for the growth of the 
young organism, whether human or animal. It is hardly necessary, 
however, to adduce this argument in favor of milk sugar, because 
there are several reasons which show that it is the most suitable 
form of sugar for well infants. It is more slowly but more com- 
pletely absorbed than the other disaccharides. Being more slowly 
absorbed, it is present for a longer time and at lower levels of the 
\intestines than the others, and is thus more conducive to the 
development and persistence of the normal fermentative flora 
throughout the intestinal tract. Few organisms, moreover, other 
than those normal to the intestinal tract of infants, utilize lactose 
before it is broken down, while many can utilize the other double 
sugars. It affords, therefore, a more efficient protection against 
abnormal bacterial processes in the intestine. 



206 SUGARS 

It is probably true that the net energy value of milk sugar is less 
than that of malt sugar, because of the greater energy presumably 
required for its utilization. It does not seem probable, however, 
that this difference is sufficient to be of practical importance. It 
has been suggested that on account of the differences in the salts of 
human and cow's milk, the sugar in the two milks may not be 
utilized in the same way. There is, however, no proof of the 
correctness of this suggestion. It has also been claimed that the 
lactose of cow's milk is not identical with that of human milk. 
There is, however, no convincing evidence in favor of this claim. 
No difference having thus far been found in the chemical composi- 
tion of lactose from different sources, it seems more reasonable, 
therefore, to consider them identical until they are proved not to 
be. It must be remembered, however, that commercial milk sugar 
is not always pure. 

No more than 7% of milk sugar should be given continuously 
in an infant's food. If for any reason a larger amount of sugar than 
this is required, the additional sugar should be given in the form of 
one of the combinations of dextrin and maltose. These sugars are 
quickly absorbed and the intestine is, therefore, not flooded with 
an excess of sugar for a long time, as it would be if milk sugar was 
used exclusively. Milk sugar is never found in the urine or feces 
under normal conditions, unless more than 7% of sugar is given. 
In fact, the assimilation limit of milk sugar, although lower than 
that of the other disaccharides, is far in excess of the amount which 
would be contained in any reasonable food. 

Lactose in reasonable amounts under normal conditions has a 
slight laxative action, as does maltose, while saccharose is slightly 
constipating. When given in excess, lactose is more likely than 
the other disaccharides to cause diarrhea, the order being lactose, 
saccharose, maltose and dextrin-maltose mixtures. The probable 
explanation of the greater frequency with which lactose causes 
diarrhea is its relatively slow absorbability. 

It is stated that lactose causes fever more readily than the other 
disaccharides, the order being lactose, saccharose and maltose. 
The fever is always accompanied by diarrhea, however, so that the 
presence of fever is no argument against the use of lactose in 
reasonable amounts under normal conditions. Schlutz's experi- 
ments render it very improbable, moreover, that, even when there 
is a rise in temperature, it is due primarily to the sugar. This so- 
called "sugar fever," provided there is such a thing, is, therefore, 
no argument against the reasonable use of milk sugar. 

When the disaccharides are added to a food which contains little 



SUGARS 



207 



or no sugar, there is a rapid increase in weight owing to the lessened 
elimination of water by the kidneys as the result of the presence in 
the organism of the products of assimilation of the sugar absorbed. 
The difference in the increase of weight with different sugars is 
due to the difference in the quantity of liquid eliminated by the 
kidneys. The gain in weight is more rapid with maltose and sac- 
charose than with lactose, probably because of the easier assimila- 
tion and more rapid absorption of these sugars. 1 This fact is the 
probable explanation of the sudden increase in weight which not 
infrequently follows the change from a modified milk prepared with 
milk sugar to one of the proprietary foods containing some com- 
pound of the dextrins and maltose. 

There can be no doubt, therefore, that under normal conditions 
the preferable sugar for the well infant is lactose. This is not the 
case, however, in many of the disturbances of digestion. Some of 
these are due to an excessive amount of milk sugar in the food. 
They can be quickly relieved by a reduction in the percentage of 
milk sugar. In others, while the disturbance is not due primarily 
to the amount of milk sugar, the chief cause of the symptoms is the 
fermentation of the milk sugar as the result of abnormal bacterial 
activity. In such instances the milk sugar must be stopped and 
some other form of sugar substituted for it. 

Maltose. — Pure maltose is never employed in the feeding of 
infants, being altogether too expensive to be used in this way. 
The various preparations to which this term is erroneously applied 
are mixtures of the various dextrins and maltose. The relative 
proportions of the dextrins and maltose are different in all of them. 
The relations of the various dextrins to each other are also different. 
The composition of a few of these preparations is as follows: 



TABLE 42 



Food 


Maltose per cent. 


Dextrin per cent. 


Soxhlet's Nahrzucker 

Loflund's Nahrmaltose 


52.44 

40.00 

51.00 

63.00-66.00 

58.91 

57.10 

58.88 

49.15 2 


41.26 
60.00 


Mead's Dextri-Maltose 


47.00 


Neutral Maltose (Maltzyme Co.) 


8.00-9.00 


Loflund's Malt-Soup Extract 


15.42 


Maltose (Walker-Gordon Laboratory) 

Mellin's Food 


30.90 
20.69 


Malted Milk 


18.80 







1 Borrino: Abstract in Archives of Pediatrics, 1911, xxviii, 869. 
2 A small proportion of the sugar is lactose. 



208 SUGARS 

The properties of maltose and the dextrins are materially differ- 
ent. Maltose is a disaccharide, dextrins are polysaccharides. 
Maltose is a crystalloid, fermentable and dialyzable; the dextrins 
are reversible, protective colloids, non-fermentable and non- 
dialyzable. It is evident, then, that it is not a matter of little 
importance which of these preparations is used. All are, of course, 
eventually absorbed in the form of dextrose. The dextrins, be- 
ing protective colloids, in all probability have a favorable influence 
on the digestibility of the protein in the same way as does starch. 
Maltose has no such action. The dextrins have to be changed to 
maltose and then to dextrose before they are absorbed. The 
larger the proportion of dextrin in the dextrin-maltose mixtures, 
the slower, therefore, is the absorption of sugar and vice versa. 
There is, consequently, less danger of overtaxing the absorptive 
mechanism of the intestine and of flooding the organism with 
sugar when the proportion of the dextrins is relatively high. On 
the other hand, if it is desired to give the sugar in a form which 
can be very readily and rapidly absorbed, the proportion of maltose 
should be large. The preparations containing relatively large 
amounts of maltose are more laxative than those containing rel- 
atively large amounts of the dextrins, because of the larger amount 
of sugar which is present at one time in the intestine. 

When the dextrin-maltose preparations are prepared in the home 
by the action of enzymes on starch solutions the character of the 
product may be varied to a certain extent. Temperatures below 
131° F. (55° C.) produce the largest amount of maltose, and above 
145° F. (63° C.) produce the dextrins in excess. A temperature of 
167° F. (75° C), however, stops the action of the enyzmes. Pure 
maltose is never produced, because after the concentration of the 
maltose reaches a certain point, the further production of dextrin, 
and therefore of maltose, is inhibited. 

Maltose is split into dextrose and dextrose which can be imme- 
diately utilized. Lactose is split into dextrose and galactose, and 
saccharose into dextrose and levulose. Only the dextrose half of 
these sugars is, therefore, immediately available without further 
change. This immediate availability of the whole of the malt 
sugar is presumably of some advantage in feeble, emaciated babies, 
who have little or no reserve of glycogen in the liver, in that all the 
energy derived from the sugar may be used immediately in the 
digestion of the rest of the food, whereas the energy of the other 
sugars is not at once utilizable, the galactose and levulose halves 
having to be converted into glycogen in the liver and then recon- 
verted into maltose and dextrose. The net energy value of malt 



SUGARS 209 

sugar is also presumably somewhat greater than that of lactose and 
saccharose, because the sugar being converted at once into dextrose, 
no further energy is required, as there is to convert the galactose 
and levulose. The immediate utilizability of malt sugar is the 
chief point in favor of the employment of this form of sugar in the 
feeding of babies not suffering from disturbances of the digestion. 
This fact, while of importance in the feeding of feeble and ema- 
ciated babies, who have but little or no reserve of glycogen in the 
liver, is of no advantage in the feeding of normal infants. In fact, 
it is probably somewhat of a disadvantage. Milk sugar, which is 
more slowly broken up and more slowly stored in the liver in the 
form of glycogen, is more suitable, in that it is less likely to overtax 
the liver and cause alimentary glycosuria and excessive fat produc- 
tion. 

Maltose, being more quickly absorbed, is less favorable to the 
maintenance of the normal fecal flora than lactose. Maltose, 
moreover, is especially conducive to the growth of the bacillus 
acidophilus, which, although normally present in small numbers, if 
present in large numbers is liable to produce an excessive degree of 
acidity, and this may cause irritation of the intestine and an intol- 
erance for sugar. Under normal conditions, therefore, as far as 
the maintenance of the normal intestinal flora is concerned, lactose 
is preferable to maltose. 

There is a form of indigestion, chiefly intestinal, in infancy due 
to the fermentation of milk sugar. In the convalescent stage of 
this condition the dextrin-maltose preparations can be given sooner 
than lactose without causing a return of the symptoms. Their use 
is, therefore, indicated in this condition. The preparations con- 
taining a relatively large proportion of dextrins are preferable, 
because they are broken down more slowly. Sugars are con- 
traindicated in diseases of the intestinal tract due to the gas 
bacillus and similar organisms. Maltose is more harmful than 
lactose because it undergoes butyric acid fermentation more 
readily. Maltose is less suitable than lactose for the feeding of 
infants ill with diseases due to the bacteria which produce toxic 
substances from protein, and non-toxic substances from carbo- 
hydrates for several reasons. Lactose is more slowly broken down 
and absorbed and consequently exerts a more prolonged action. 
In the next place, few organisms except those normal to the in- 
testinal tract of infants can utilize it before it is broken down by 
hydrolysis. There is also danger, as already pointed out, if mal- 
tose is given freely, of encouraging the overdevelopment of the 
bacillus acidophilus and developing a sugar intolerance. 



210 SUGARS 

Cane Sugar. — There seems to be no evident reason for using 
cane sugar in place of milk sugar in feeding normal infants except 
that it is less expensive. It is true that many infants thrive on it. 
This fact, however, does not prove that it is preferable to milk 
sugar, because the average normal infant is able to utilize lactose, 
saccharose or the dextrin-maltose mixtures indiscriminately, pro- 
vided they are not given in excess. That is, normal babies that 
thrive on cane sugar do so in spite of it, not because of it. Cane 
sugar, undergoing as it does alcoholic fermentation instead of 
lactic acid fermentation, is less suitable for the development and 
maintenance of the normal intestinal flora than milk sugar. Grant- 
ing that the experimental evidence that the assimilation limits of 
cane sugar are greater than those of milk sugar and that it is less 
likely to cause diarrhea and " sugar fever" than milk sugar is 
correct, which is certainly open to question, even then it is inferior 
in all these respects to the dextrin-maltose mixtures. Therefore, 
if there is any reason to believe that there is a disturbance of the 
digestion from the presence of milk sugar in the food, the dextrin- 
maltose mixtures should be substituted for the milk sugar, not 
cane sugar. The dextrin-maltose mixtures are also preferable to 
cane sugar in the feeding of feeble, emaciated infants to whom it is 
desirable to give a rapidly utilizable sugar because, like milk sugar, 
it is only half dextrose, the levulose being available only after 
further changes. 

It is stated that, when used continuously, cane sugar has a 
slightly constipating action, while milk sugar and the dextrin- 
maltose mixtures are slightly laxative. This action is, however, 
hardly strong enough to be of any practical importance. 

Starch. — It has been proved beyond question that amylolytic 
ferments are present in the saliva and pancreatic secretions of the 
new-born infant, even if it is born prematurely. These ferments 
are present and active in the breast-fed as well as in the artificially- 
fed infant. The amylase of the pancreatic secretion is more abund- 
ant after the first month than earlier. After the first month the 
activity of the pancreatic amylase seems to depend more on in- 
dividual peculiarities than on the age of the baby. The amount 
of the secretion is apparently independent of the character of the 
food. It is not diminished in atrophic conditions. There are, 
therefore, no physiologial contraindications to the use of starch in 
the feeding of infants, even of the new-born. This fact does not 
prove, however, that infants ought always to be given starch or 
that they should be fed on foods composed largely or almost ex- 
clusively of starch. It merely shows that there is no reason why 



STARCH 211 

starch should not be given to babies, if there is any good reason for 
using it. Clinical experience shows that, in general, it is not 
advisable to give starch to babies under two months old, although 
there are many exceptions to this general rule. Clinical experience 
also shows that it is inadvisable to give large amounts of starch to 
babies before they are ten months old. It shows, on the other hand, 
however, that many babies do far better on foods containing starch 
than they do on foods which do not contain it. Starch should be 
used in the food of infants in the same way as the sugars, fat and 
protein, that is, intelligently and for definite purposes and indica- 
tions. The percentage of starch in the food should be just as 
carefully calculated as that of any of the other elements. 

The caloric value of starch is, for practical purposes, the same as 
that of sugar, the loss of nutritive value resulting from the greater 
energy expended in breaking down the starch being, for every-day 
work, negligible. The starch is, of course, ultimately converted 
into dextrose before it is utilized. Starch is used less frequently, 
however, primarily for its nutritive value than for its other prop- 
erties. 

Starch acts as a protective colloid and in this way prevents the 
formation of large casein curds. This action is due to the soluble 
starch itself, not to the salts or to cellulose in suspension. It has 
been found that percentages of starch greater than 0.75% in milk 
mixtures have no more effect in diminishing the size of the curds 
than does 0.75%, while smaller percentages have less effect. When 
starch is added simply for its effect on the coagulation of casein, 
0.75% is, therefore, the optimum amount. 1 This amount of starch 
is very seldom outside of the limit of tolerance of even the youngest 
and feeblest infant. 

Starch is very useful when it is desirable to give carbohydrates 
to infants in whom the sugars cause fermentation or in whom the 
tolerance for sugars is so low that they cannot be given in sufficient 
quantities to supply the caloric needs which cannot be met by fat 
and protein. The probable reason that babies can take carbo- 
hydrate in the form of starch, when they cannot take it in the 
form of dextrins and sugar, is that the molecular structure of 
starch is more complicated than that of the dextrins and sugars. 
The more complicated the structure of a carbohydrate is, the more 
numerous are the steps in its breaking down to its end products. 
There are, therefore, less fermentable materials in the intestine at 
one time and less opportunity is afforded for fermentation to get 
the upper hand. 

1 White: Journal of Boston Society of Medical Sciences, 1900, v, 125. 



212 STARCH 

Starch is used in infant feeding in the form of the cereal waters 
or gruels. The nutritive value of these waters and gruels rests al- 
most entirely in the starch which they contain. The cereal waters 
contain about 1.50% of starch, 0.20% of protein and from 0.01% to 
0.05% of fat. The gruels contain about twice as much of each 
element. 1 When it is remembered that these cereal preparations 
are used merely as diluents it is evident that the food value fur- 
nished by the fat in them is essentially nil, and that furnished 
by the protein negligible. Cereal diluents made from the whole 
grains contain more protein, however, then those made from the 
corresponding flours. 

Starch is most commonly used in the form of barley or oat flour. 
Barley flour is usually considered to be somewhat constipating and 
oat flour to have a slightly laxative action. The action of these 
flours on the intestinal peristalsis is, however, not at all a constant 
one, barley starch having a laxative and oat starch a constipating 
action in some infants. Other forms of starch have been used but 
little in this country and it has been rather taken for granted that 
it makes but little difference what form of starch is used. This is 
probably true in most instances and when small amounts only are 
used. The investigations of Nagao 2 and Klotz, 3 show that barley 
and oat starch are broken down more rapidly by enzymes and bac- 
teria than are wheat and rye starch. The former flours are more 
likely, therefore, to cause acidity and fermentation than the latter. 

It must not be forgotten, however, that, while starch in reason- 
able amounts is often most useful in feeding infants, it may, if 
given in excessive amounts, cause very marked disturbances of 
digestion and of nutrition. The fermentation of starch results in 
the formation of free fatty acids, which exert a strong irritant 
action on the intestines and cause increased peristalsis. The in- 
jurious effect of these acids is the same, whether they are derived 
from carbohydrates or fat. 4 

On the other hand, an excessive amount of starch not infre- 
quently causes constipation. The stools in such cases are hard, 
dry and light-brown, resembling the soap stool except in their color. 

A baby on a purely carbohydrate diet or on one in which the 
carbohydrates are greatly in excess receives much less salts than it 
should, such a diet being poor in salts. The consequent disturb- 
ance in the retention of salts and water results in impairment of 

*Ladd: Archives of Pediatrics, 1908, xxv, 256. 
*Nagos: Zeitschr. f. experiment. Path. u. Therapie, 1911, ix, 227. 
s Klotz: Archiv. f. experiment. Path. u. Pharmacol., 1912, lxvii, 451. 
4 Stolte: Jahrb. f. Kinderheilkunde., 1911, lxxiv, 367. 



POLYCARBOHYDRATES 213 

the nutrition and in marked diminution in the resistance to infec- 
tion. 1 Serious disturbances of nutrition from the excessive use 
of starchy foods, although apparently common abroad, are fortu- 
nately comparatively rare in this country. 

Polycarbohydrates. — Attention has recently been called to the 
use of " poly carbohydrates" in infant feeding. Those who use 
this term mean by it a combination of several carbohydrates in the 
same food. They believe that, on account of the difference in the 
rapidity of absorption of the different carbohydrates, more car- 
bohydrate can be given in this way without overtaxing the power 
of the organism to assimilate and utilize sugar than when a single 
carbohydrate is used. This belief is unquestionably correct and 
there is no doubt that when there is a disturbance in the digestion 
of sugar it is of great advantage to give some of the carbohydrate 
in the form of starch. The rationale of the use of the dextrin- 
maltose mixtures and starch has already been considered in dis- 
cussing these substances. Those who advocate the use of "poly- 
carbohydrates" in infant feeding seem to forget, however, that 
mixtures of milk and cereal waters contain two carbohydrates, 
milk sugar and starch, and mixtures of milk, dextrin-maltose mix- 
tures and cereal waters four carbohydrates, milk sugar, malt sugar, 
dextrins and starch. The principle is, therefore, not a new one. 
Owing to the inferiority of cane sugar to the other sugars as a food 
for infants and the comparatively slight difference in the fer- 
mentability of the various forms of starch, it hardly seems neces- 
sary to complicate the mixtures further by the addition of cane 
sugar and by the use of several varieties of starch in the same food. 
The mixtures of milk, dextrin-maltose mixtures and simple cereal 
waters contain the carbohydrates in sufficient variety to meet the 
indications for the " polycarbohydrates." The malt sugar is ab- 
sorbed first, then the milk sugar, next the dextrins and finally 
the starch. The absorption is thus comparatively slow and con- 
tinues for a long time. The sudden flooding of the organism with 
sugar is thus avoided. 

Protein. — While the fats and carbohydrates can, with certain 
restrictions which have been considered elsewhere, be used inter- 
changeably in feeding babies, neither can take the place of protein. 
The protein is essential to life, in that it is the only form of food 
which can replace the nitrogenous waste of the body and from 
which new cells can be built up. It is indispensable for the repair 
and growth of the body. New tissue cannot be formed from 
carbohydrates and fat. They serve as sources of energy. Protein 
^alge: Jahrb. f. Kinderheilkunde., 1912, Ixxvi, 125. 



214 PROTEIN 

can also serve as a source of energy and life can be sustained for 
considerable periods of time on a purely protein diet. Such a diet 
is, however, a wasteful one, throws an excessive amount of work 
on the organs of digestion and metabolism and seriously overtaxes 
the organs of elimination. 

The protein need of the infant is much greater than that of the 
adult, in that it not only requires protein to replace tissue waste but 
also to build up new tissues. If the protein content of its food is 
below a certain level, it will eventually die of malnutrition, no 
matter how high the caloric value of the food. If the protein 
content is just high enough to cover the tissue waste and a little 
more, the baby will live, but it will not thrive properly. It may 
become fat, but it cannot form bone and muscle as it should. The 
cause of anaemia, obscure disturbances of nutrition, delay in mus- 
cular development and various functional derangements of the 
nervous system in infancy is not infrequently a deficiency of pro- 
tein in the food. The average protein need of infants is at least 1.5 
grams per kilogram, or 0.7 grams per pound of body weight. 
In all probability, many babies require as much as 2 grams per 
kilogram, or 0.9 grammes per pound of body weight. Unless a 
baby gets this amount of protein in its food, it cannot thrive. It 
can often take much more than this with advantage. 

The most available and the most easily digestible form of pro- 
tein for infants is the protein of milk. The protein of woman's milk 
is more digestible than that of cow's milk. A part of the protein 
may be given in the form of vegetable protein, but vegetable pro- 
tein cannot permanently replace animal protein in the infant's 
food. 

There is no doubt that the opinion held some years ago that the 
protein was the most indigestible portion of cow's milk for infants 
and that the disturbances of digestion occurring in infants fed on 
cow's milk were almost entirely due to the protein, was an erro- 
neous one. It is probable, on the other hand, that at the present 
time the tendency is to minimize the possible power of protein to 
cause disturbances of digestion and metabolism and to attach too 
little importance to it. One cause for this tendency is presumably 
that the disturbances caused by the proteins are, like those caused 
by the salts, less easily recognizible than those caused by the 
carbohydrates and fats. It has recently been shown, for example, 
than an excessively high protein diet will cause fever 1 and a con- 
dition of semistupor. 2 The products of protein metabolism, when 

1 Holt and Levene: American Journal of Diseases of Children, 1912, iv, 265. 

2 Hoobler: American Journal of Diseases of Children, 1915, x, 153. 



PROTEIN 215 

in excess, undoubtedly irritate the kidneys. Further undesirable 
results of an excessive amount of protein will, in all probability, 
be discovered as the subject is more carefully studied. 

The relation of the casein to the whey protein in human milk is 
approximately as 1 is to 2, while the relation in cow's milk is as 
3 to 1. While it is possible, and perhaps probable, that there are 
considerable chemical differences between the protein of human 
milk and that of cow's milk, this is not proven. Setting aside, how- 
ever, the undoubtedly important but still problematical action 
of the salts of the two milks on the digestibility of the protein, in 
the light of our present knowledge, the chief cause of the difference 
in the digestibility of the protein of human milk and that of cow's 
milk lies in the greater proportion of casein in cow's milk. In the 
first place, the absolutely greater amount of casein in cow's milk 
favors the formation of large, tough, casein curds, while the rela- 
tively smaller proportion of the whey protein to casein diminishes 
its colloidal action in the prevention of the coagulation of the 
casein. 

It is the formation of large curds which renders the casein of 
cow's milk so much more difficult of digestion by the infant than 
that of human milk. If the formation of large casein curds in the 
stomach can be prevented, the casein of cow's milk is easily di- 
gested. Fortunately, the average normal infant can digest con- 
siderable amounts of cow's milk casein in the usual dilutions with- 
out anything being done to prevent the formation of large casein 
curds. It is of a certain disadvantage, moreover, to render the 
digestion of the casein too easy, because, if this is done, the 
development of the digestive powers is not encouraged as it 
should be. 

Methods of Preventing the Formation of Casein Curds. Re- 
duction of the Amount of Casein. — The simplest method of pre- 
venting the formation of casein curds is by diminishing the amount 
of the casein and thus giving it more diluted. In using this method, 
however, great care must be exercised not to reduce the casein 
so much that the protein need is not covered. Some other method 
is, therefore, usually preferable. 

Whey Mixtures. — One of the best methods of giving the pro- 
tein in an easily digestible form is the whey mixture. The whey 
protein is not coagulable by rennin and, therefore, cannot form 
curds. Moreover, by its colloidal action it hinders the formation 
of large, casein curds. The presence of the protein in the whey 
makes it possible to diminish the casein materially without in- 
curring the danger of protein starvation which is always present 



216 PROTEIN 

when the casein is reduced by simple dilution. The whey mixture 
is less valuable when the food is prepared at home than when it is 
prepared at a milk laboratory, because, when gravity cream is used, 
as it has to be in the home, the amount of cream which has to be 
used in order to have sufficient fat in the mixture carries with it a 
considerable percentage of casein and consequently reduces the 
amount of protein which can be given in the whey. When whey 
mixtures are prepared at a milk laboratory, however, where high 
percentage creams can be used, the casein can be made very low 
and the whey protein high. 

Whey mixtures are also very useful when there is much vomiting, 
the whey protein, not being acted on by rennin, leaving the 
stomach very rapidly. 

Cereal Diluents. — Another method of hindering the forma- 
tion of large, casein curds is by the addition of cereal diluents, 
such as barley water, to the food. The soluble starch in these 
cereal diluents acts as a protective colloid. The salts and the 
suspended cellulose probably play no part in the action of these 
diluents. It has been found that percentages of starch greater 
than 0.75 in milk mixtures have no more effect in diminishing the 
size of the curds than does 0.75%, while smaller percentages are 
less effective. When a cereal diluent is added to an infant's food 
for the purpose of preventing the formation of large, casein curds, 
it should, therefore, be added in such a way that the starch con- 
tent of the mixture is 0.75%. 

Boiling. — One of the most effective, as well as one of the sim- 
plest, methods of preventing the formation of large, casein curds 
is the boiling of the food. When rennin is added in vitro to raw 
milk and the mixture kept at the proper temperature, a dense, 
hard coagulum, which separates completely from the whey, is 
quickly formed. When rennin is added to boiled milk, however, 
coagulation takes place more slowly, and the curd which is formed 
is soft and fine. The separation of the curd and whey is also 
much less complete than in raw milk, so that the appearance of the 
liquid is that of a thick homogeneous fluid. The experiments of 
Brennermann * and others show that the same differences in the 
coagulation of the casein of raw and boiled milk by rennin exist 
in the stomach as in vitro. The food must be boiled hard at least 
five minutes in a single boiler in order to prevent the formation 
of large curds. Simmering in a double boiler is not effective. 

Alkalis. — The addition of an alkali to milk unquestionably 
hinders or prevents the formation of large, hard curds in the 
1 Journal A. M. A., 1913, lx, 575. 



PROTEIN 217 

stomach. There is much difference of opinion as to exactly how it 
does this and as to exactly what chemical changes take place in 
the gastric digestion of casein as the result of the addition of an 
alkali. The most probable explanation of these differences of 
opinion is that the exact details of the digestion of casein are even 
now but imperfectly understood. The nomenclature of the various 
products which are formed is, moreover, not a settled one. The 
coagulation of the milk in the stomach by rennin is unquestionably 
delayed by the addition of an alkali, because rennin does not act in 
an alkaline medium. How much it is delayed depends, with a 
given amount of alkali, on the acidity of the milk, which in clinical 
work is always an unknown quantity. The more acid the milk, the 
more of the alkali is required to neutralize it and the less is left to 
neutralize the hydrochloric acid secreted by the stomach and vice 
versa. When pure, clean milk is used, the part played by the 
acidity of the milk is probably relatively unimportant. During 
this period of delay it is generally believed that some of the un- 
coagulated milk leaves the stomach, the amount of milk which 
passes into the duodenum varying directly with the length of time 
before coagulation takes place. Certain authorities claim that the 
milk cannot leave the stomach under these conditions, because the 
pylorus does not open until the reaction on the stomach side is 
acid. Others state that milk, before it is coagulated, leaves the 
stomach quickly in gushes, like water, independent of the pyloric 
reflex. 1 When coagulation does occur the curds formed are more 
granular and softer than the tough curds of calcium paracasein 
which are ordinarily formed. 

Whatever the action of the alkali may be, there is no doubt that 
it consists partly in neutralizing the acidity of the milk and partly 
in neutralizing the hydrochloric acid secreted by the stomach, 
thereby changing the combination of the calcium salts with casein. 
It is evident, therefore, that, as regards the neutralization of the 
acidity of the milk, whatever alkali is used, the amount to be 
added to the food should be determined by the amount of milk and 
cream in the food, which determine its acidity and which alone 
contain casein, not in relation to the total quantity of the mixture. 
It is impossible in ordinary clinical work to know how much alkali 
to add, because the acidity of the milk is always an unknown 
quantity. Experience has shown, however, that, when lime water 
is used as the alkali, from 25 to 50% of lime water must be added 
to average milk in order to produce any appreciable effect. The 
alkaline action of lime water is less than would be expected, be- 
1 Cannon: The Mechanical Factors of Digestion, 1911, p. 115. 



218 PROTEIN 

cause of the using up of its soluble alkalinity in the precipitation 
of insoluble calcium phosphate in the milk. 1 

Bicarbonate of soda or other alkalis are sometimes used in place 
of lime water. One and one-half grains of bicarbonate of soda is 
equal to about an ounce of lime water. The action of lime water 
and bicarbonate of soda is, however, somewhat different. Lime 
water swells the mucoid protein of milk, which probably has some 
effect on the precipitation of the casein, while the carbonic acid 
gas which is formed from bicarbonate of soda during digestion tends 
to make the curds more porous. 

Citrate of Soda. — Citrate of soda is of considerable value in 
the prevention of the formation of large, tough curds. Under 
ordinary conditions rennin splits calcium caseinate into calcium 
paracaseinate which is insoluble. The citrate of soda combines 
with the calcium caseinate of the milk to form sodium caseinate 
and calcium citrate. Rennin splits sodium caseinate into sodium 
paracaseinate, which is very soluble. Therefore no precipitation 
or curdling takes place. 2 One or two grains of the citrate of 
soda to the ounce of milk or cream in the mixture is the quantity 
usually employed. Two grains to the ounce is probably more 
effective than one grain. 

Buttermilk. — The casein in buttermilk and other forms of milk 
in which lactic acid forming organisms have been allowed to grow 
is in a form in which it cannot be acted upon by rennin. The 
formation of large, hard curds is, therefore, prevented. The casein 
is said to be in the form of the lactate of casein, this having been 
formed as the result of the combination of the lactic acid produced 
by the bacteria with the casein. This statement seems very 
doubtful, however, as casein acts as an acid and two acids cannot 
combine. Some of the casein has also presumably been more or 
less digested by bacterial action. The casein in buttermilk is in a 
finely divided condition as the result of the mechanical action of 
the churning. Boiling buttermilk does not affect the chemical 
combination of the casein. 

Protein Milk. — A considerable part of the casein in the so-called 
Eiweissmilch or, in English, protein or albumin milk, has already 
been precipitated by rennin in the form of calcium paracasein. 
When taken into the stomach it, therefore, cannot be acted upon 
again by rennin. The paracasein curds have been, moreover, very 
finely divided by being rubbed through sieves in the preparation of 

1 Bosworth and Bowditch: Journ. Biolog. Chem., 1916-17, xxviii, 431. 
2 Bosworth and Van Slyke: Technical Bulletin No. 34, New York Agri- 
cultural Experiment Station. 



SALTS 219 

the food. The casein furnished by the buttermilk in the food is, as 
has already been explained, in the form of the " lactate of casein. " 
The formation of large, tough curds in the stomach is, therefore, 
impossible. 

Pancreatization. — Another method of preventing the formation 
of large curds is by the partial predigestion of the food. This 
is commonly known as peptonization but is in reality pancreatiza- 
tion, the active ferment being the trypsin of the pancreas. A part, 
at least, of the casein is so far digested that it cannot be acted 
upon by rennin. The formation of hard curds in the stomach is, 
therefore, more or less interfered with, the amount of interference 
depending on how far the process of pancreatization has been 
carried. 

Salts. — The various salts, with the exception of iron, are present 
in sufficient quantities and in proper proportions in human milk. 
In most modifications of cow's milk there is an excess of salts and 
the proportions of the various salts are different from those in 
human milk. The normal infant can, as a rule, thrive in spite of 
this excess of salts and in spite of their, for the infant, abnormal 
relation to each other. There is no doubt, however, that a part, 
perhaps a considerable part of the disturbances of digestion in 
infants fed on modifications of cow's milk are due to the excess and 
abnormal relations of the salts in them. It does not seem reason- 
able, nevertheless, to go as far as some pediatricians and attribute 
all the disturbances of digestion to them. At present, however, our 
knowledge concerning the salts, the part which they play in normal 
digestion and metabolism and the symptoms of the disturbances 
which they cause is so limited and incomplete that we can pay but 
little attention to them in the regulation of the diet either in health 
or in disease. 

The Relation of the Different Elements of the Food to Each 
Other. — Thus far the different elements of the food and the dis- 
turbances of digestion to which they may give rise have been con- 
sidered as if they always occurred independently of each other. 
This point of view is, however, a mistaken one. It is wrong to 
think so much, as is now the custom, of the disturbances of diges- 
tion caused by single elements of the food. There can be no doubt 
that in many instances in which the disturbance appears to be 
due to a single element, the real trouble is in the relation of the 
different elements to each other. Our knowledge of the connection 
of the disturbances of digestion with the various food elements is 
still extremely rudimentary, and we must be very careful not to 
accept each new item of information as the final solution of the 
problem. 



220 BUTTERMILK 

Special Preparations of Milk used in Infant Feeding. — Various 
special preparations of milk have been used in infant feeding with, 
according to those who have employed them, unusually favorable 
results. The most important of them are buttermilk and protein 
milk. 

Buttermilk, — Buttermilk made from sweet milk in the manufac- 
ture of butter is, of course, nothing but skimmed milk. It con- 
tains from 0.50% to 1.0% of fat, about 4.5% of milk sugar and 
3.8% of protein, the relation of the casein and the whey protein 
being the same as in whole milk. 

Buttermilk is usually made from cream soured either naturally 
or by the addition of lactic acid bacteria. The composition of 
buttermilk obtained in this way is not a constant one. Average 
figures are: fat, 0.5% to 1.0%; milk sugar, 3.0% to 3.5%; pro- 
tein, 2.5% to 2.7%. The proportion of whey protein is relatively 
higher than in whole milk. The casein is very finely divided as the 
result of the centrifugalization and is separated from its calcium 
base. It is already clotted in the form of the "lactate of casein" 
and can no longer be acted upon by rennin. The caloric value of 
buttermilk varies between 300 and 400 calories per liter. A fair 
average figure is 360 calories per quart. 

Good buttermilk should not contain over 0.50% of lactic acid. 
There is a tendency for the acidity to increase with time, although 
it rarely reaches over 0.75%, at which point the buttermilk sep- 
arates into curds and whey. The lactic acid organisms which 
caused the souring of the milk, as well as other organisms, are alive 
and active. Heating buttermilk destroys the fine division of the 
casein and causes it to clot in large masses like ordinary cow's 
milk. It also destroys the bacteria which it contains. Heated 
buttermilk is, therefore, no better than sour skimmed milk. This 
clotting may be prevented by constant, violent stirring or beating 
while it is being heated. 

Buttermilk has been used as a food for infants since at least as 
early as 1770, and good results have unquestionably been obtained 
with it. This is readily understood when its composition is remem- 
bered. It contains a low percentage of fat, a rather low percentage 
of sugar and a relatively high percentage of protein, the proportion 
of whey protein being relatively greater than in plain milk. The 
casein is finely divided and in a form which cannot be acted on by 
rennin. It is highly acid from the presence of lactic acid and con- 
tains many bacteria, the lactic acid forms predominating. It 
should be useful, therefore, in those conditions in which a low fat 
and a high, easily digestible protein is indicated. The lactic acid 



BUTTERMILK 221 

organisms which it contains should also be of advantage in those 
disturbances of digestion which are due to organisms to which 
the lactic acid bacteria are antagonistic. This possible advantage 
is lost, of course, when buttermilk is pasteurized or boiled. 

Most of those who have employed and recommended the use of 
buttermilk as a food for infants have, however, not used it plain. 
They have added from 10 to 25 grams of flour, usually wheat, 
and from 35 to 90 grams of cane sugar to a liter of buttermilk and 
then boiled it with much stirring. The nutritive value of the 
buttermilk is thus materially increased, while the other char- 
acteristics are unchanged, except that the lactic acid bacteria are 
destroyed. The caloric value of buttermilk prepared in this way 
varies between 525 and 700 calories per liter, the additional 
calories being furnished by the cane sugar and starch which have 
been added. 

It does not seem rational to use buttermilk, with or without the 
addition of cane sugar and starch, as a routine food for all babies, 
whether sick or well. It is far more reasonable to adopt the good 
points in it and utilize them in combination with percentage feed- 
ing. 1 There is no special advantage in using buttermilk in cases in 
which a low percentage of fat is indicated, because a low percentage 
of fat can be more easily given in other ways. The peculiar form of 
the casein in buttermilk may be of considerable value in instances 
in which there is a disturbance of the digestion of casein. If plain 
buttermilk or stock preparations of buttermilk are used, the 
percentages of fat and sugar cannot be varied to suit the needs of 
the individual baby. If a modified milk is prepared to fit the needs 
of the individual infant at the time and the character of the casein 
then changed by the action of lactic acid bacteria, the chief ad- 
vantage of buttermilk is thus retained and yet the food is in other 
ways fitted to the needs of the baby. It is probable that the 
degree of the acidity of the buttermilk plays some part in its 
action. This cannot be regulated in commercial buttermilk, but 
can be when the milk is soured by the addition of lactic acid 
bacteria, since the production of acid can be stopped at any time 
by boiling the mixture. When the change in the character of the 
protein is all that is desired, the mixture should be boiled when the 
acidity is between 0.25% and 0.50%. Twenty-five hundredths 
per cent of lactic acid just curdles milk while 0.50% gives thick 
curdled milk. An acidity of from 0.50% to 0.70% is usually at- 
tained in from twelve to eighteen hours. 

When the action of the lactic acid bacteria on the intestinal 
1 Morse and Bowditch: Archives of Pediatrics, 1906, xxiii, 889. 



222 PROTEIN MILK 

bacteria is what is desired, the mixture should not, of course, be 
boiled. The acidity should not, however, run much above 0.50%. 

Other objections to the use of commercial buttermilk are that 
the acidifying organisms are usually of several varieties and that 
the milk contains a variety of other organisms which have grown 
at the same time, many of which are undesirable. It is far wiser, 
therefore, to prepare foods for babies by the addition of pure cul- 
tures of lactic-acid-forming organisms to pure or boiled milk. The 
danger of infection by other organisms is thus avoided. The 
bacillus Bulgaricus is the one perhaps most commonly used. It is 
liable, however, to make the taste of the milk too acid. Another 
organism, perhaps better, is the bacillus acidi paralactici. Cul- 
tures of lactic-acid-forming organisms are now easily obtainable 
from milk laboratories and chemists. Better results are usually 
obtained by the use of a " starter" than by the use of a new culture 
each time. 1 Cultures are much preferable to the various lactic acid 
tablets on the market, many of which are inert and none of which 
are as active as cultures. 2 

Protein Milk (Eiweissmilch, Casein Milk, Albumin Milk). — 
Finkelstein and Meyer conclude from their observations that 
sugar is the special and primary cause of intestinal fermentation 
and that the fat is never involved primarily. They believe that 
the fermentation of the sugar is dependent on two main factors: 
the concentration of the whey and the relative proportions of 
casein and sugar in the mixture. They conclude, therefore, that 
the principles on which the preparation of a food to combat intes- 
tinal fermentation depend are: a diminution in the quantity of 
milk sugar, a diminution of the salts through dilution of the whey, 
and an increase in the casein, with varying, and, under certain cir- 
cumstances, not inconsiderable amounts of fat. After improve- 
ment has begun, an easily assimilable and consequently little 
fermentable carbohydrate should be added. They consequently 
developed a food to meet these indications to which they gave the 
name of Eiweissmilch. This food is prepared as follows: Heat one 
quart of whole milk to 100° F. Add four teaspoonfuls of essence of 
pepsin and stir. Let the mixture stand at 100° F. until the curd has 
formed. Put the mass in a linen cloth and strain off the whey 
from the curd. Remove the curd from the linen cloth and press it 
through a rather fine sieve two or three times by the means of a 
wooden mallet or spoon. Add one pint of water to the curd during 
this process. The mixture should now look like milk and the 

1 Morse and Bowditch: Archives of Pediatrics, 1906, xxiii, 889. 
8 Heinemann: Jour. Amer. Med. Ass'n, 1909, lii, 372, and 1912, lviii, 1252. 



PROTEIN MILK 223 

precipitate must be very finely divided. Add one pint of butter- 
milk to this mixture. 

Finkelstein and Meyer used buttermilk in the preparation of 
this food for the following reasons: 1, because of the small amount 
of milk sugar which it contains; 2, to obtain the good effects of the 
lactic acid, and 3, because buttermilk can be kept for a long time. 

The composition of this food is : 

Fat ...2.5% 

Sugar '..1.5% 

Protein 3.0% 

Salts 0.5% f 

One quart of this milk contains about 370 calories. 

They call attention to the low caloric value of this food and to 
the necessity of increasing it as soon as possible by the^addition of 
dextrin-maltose mixtures. 

They claim that it is worthy of employment in all the disturb- 
ances of nutrition in infants which are accompanied by diarrhea 
of no matter what sort or variety. The use of this food has been 
extended by others to all sorts of conditions, including the feeding 
of well infants and the newly-born, and good results claimed for it. 

The principle of the treatment of fermentative conditions caused 
by sugar with a food low in sugar and salts and high in protein is 
a rational one, as is the substitution of the dextrin-maltose mix- 
tures for lactose. It hardly seems rational, however, to believe 
that all disturbances of nutrition accompanied by diarrhea are 
due to the same cause and should be treated in the same way. 
Neither does it appear reasonable to think that any method of 
feeding can be applicable to both the sick and the well or to give 
all babies the same food without regard to their individual digest- 
ive capacities. 

It is possible, however, to take advantage of the main principles 
of this method of treatment of the intestinal fermentative condi- 
tions and at the same time avoid the disadvantages of a routine 
food by applying them in the modification of milk by the percent- 
age method. The buttermilk seems to be an unnecessary addition, 
because the low salt and high casein content, which form the 
raison d'etre of the food, can be obtained perfectly well without it. 
It is possible by the use of cream containing a high percentage of 
fat to reduce the amount of unprecipitated casein and whey protein 
to a very small percentage and yet have any desired percentage 
of fat in the mixture. The percentages of salt and sugar are also 
kept low because of the small amount of cream required. Any per- 



224 PROTEIN MILK 

centage of casein desired can then be added in the form of precip- 
itated casein prepared according to Finkelstein and Meyer's 
method. The advantages of this method of treatment of ferment- 
ative intestinal conditions are retained in this way and the dis- 
advantages of a routine method avoided. The dextrin-maltose 
mixtures can be added, of course, when desired, and the percent- 
age of salt increased by the substitution of creams containing 
lower percentages of fat. 

The preparation of protein milk and of modifications of milk 
made with precipitated casein is a difficult matter outside of milk 
laboratories or institutions. This method of treatment is, there- 
fore, hardly applicable in the home. The addition of dried, pow- 
dered casein and paracasein to mixtures made in the ordinary way, 
as suggested by Bowditch and Bosworth * offers another method 
of combining low percentages of sugar and salts with a high per- 
centage of casein. This method is, moreover, much simpler and 
can be carried out in the home as well as in institutions or milk 
laboratories. 

1 Amer. Jour. Diseases of Children, 1913, vi, 394. 






CHAPTER XVIII 
THE PRESCRIBING OF MODIFIED MILK 

The first thing to do in prescribing modified milk for an infant 
is to determine what percentages of fat, sugar, protein and starch 
shall be in the mixture. The next things to decide are whether the 
sugar shall be in the form of milk sugar, cane sugar or one of the 
dextrin-maltose mixtures and whether a part of the protein shall 
be given in the form of whey protein or not. It is then necessary 
to determine whether an alkali shall be added or not and, if it is 
added, what form shall be used and how much of it. Finally it 
must be decided whether the mixture shall be given raw, pasteur- 
ized, and if so, at what temperature, or boiled. After all these 
points are settled, the number of feedings and the amount at each 
feeding must be decided, bearing in mind in this connection that 
the total quantity given in the twenty-four hours is far more im- 
portant than the number of feedings and the size of the individual 
feeding. It is advisable, after deciding upon the total quantity, 
to calculate the caloric value of the food and the amount of protein 
which it contains in order to know whether the caloric and protein 
needs are being covered or greatly exceeded. In most instances 
the food decided upon should be given, even if its caloric and pro- 
tein content do not correspond to the established standards. The 
knowledge of these points will, however, often prove of great assist- 
ance in changing the food in the future, if the baby does not thrive 
on it. In special cases it is also necessary to determine whether 
the mixture shall be acted upon by lactic acid organisms or not, 
and, if so, whether or not they shall be destroyed by heat; in others, 
whether some form of protein milk (Eiweissmilch) shall be used or 
the milk pancreatized. 

Every one of these points must be decided every time that a 
modified milk mixture is prescribed. No single one of them can 
be omitted. They must be decided, moreover, not by following 
blindly the rules of some authority on infant feeding or by picking 
a formula from a table in some text-book, but on the indications 
in the given case at the given time. 

When the composition and the amount of the food have been 
decided, the food may be prepared either at a milk laboratory or in 

225 



220 THE PRESCRIBING OF MODIFIED MILK 

the home. When the milk is to be prepared at a milk laboratory, 
it is only necessary to write a prescription for the food, embodying 
the points already determined. Most milk laboratories have a 
prescription form in which it is only necessary to fill in the blank 
spaces. This form, while a convenience, is in no way a necessity. 
The physician who is competent to prescribe modified milk mix- 
tures has no need of a form. On page 227 is a copy of the prescrip- 
tion form furnished by the milk laboratories in the neighborhood 
of Boston. 

There is no doubt that a milk laboratory can prepare mixtures 
of modified milk more accurately than they can be prepared in the 
home. The milk and cream can be analyzed daily in the laboratory 
and the sugar and starch accurately weighed, so that the mixtures 
can be made from materials of known composition. This cannot 
be done in the home. Whether the formulae are actually put 
up more accurately in the laboratory than in the home depends, 
however, on the care exercised in the individual laboratory at the 
given time. The employees in milk laboratories are human and 
are, therefore, liable to be careless and to make mistakes. Another 
advantage which the milk laboratories have is that they own their 
own farms and can, therefore, be sure of having a clean milk from 
which to prepare the food. The individual preparing the food at 
home, unless able to procure a certified milk, can never be sure 
whether the milk is clean or not. 

The price of modified milk, prepared at milk laboratories, is no 
higher than it should be, when the character of the materials used, 
the labor required in the modification of the milk and the cost of 
delivery are taken into consideration. The price is, nevertheless, 
prohibitive for poor people. If the milk has to be sent any distance 
and express charges added, only the well-to-do can afford to have 
it. Comparatively few babies can be fed, therefore, on modified 
milk prepared at a milk laboratory. The vast majority, either 
because of the expense or the distance from a laboratory, must be 
fed on mixtures prepared in the home. 



THE HOME MODIFICATION OF MILK 

Modifications of milk for infant feeding cannot be prepared as 
accurately in the home as at a milk laboratory, because it is im- 
possible in the home to know the exact composition of the materials 
used in the preparation of the mixtures. If reasonable care is used 
in their preparation, however, the inaccuracies are not as great as 
would be supposed. In fact, in the vast majority of instances, 



THE PRESCRIBING OF MODIFIED MILK 



227 



R 

Fats. 



(a) Carbohydrates 



(b) Dextrinize 

(c)Proteidsj CaJem 

(d) Peptonize 

(e) Sodium Citrate 



Lactose (Milk Sugar) 
Maltose (Malt Sugar) 
Sucrose (Cane Sugar) 
Dextrose (Grape Sugar) 
Starch 



f%of 
\%of 



(f) Sodium Bicarb. { 



milk and cream 
total mixture 
% of milk and cream 
| % of total mixture 



/ \ t • ttt A f % of milk and cream 
(g) Lime Water j ft of total mixture 



(h) Lactic Acid 
Bacillus 

Heat at 



1 To inhibit the saprophytes of fer- 

mentation 

2 To facilitate digestion of the pro- 

teids 



Per Cent. 



Number of Feedings 

Amount at each Feeding 



ORDERED FOR 



ADDRESS- 
DATE 



-19 



-M. D. 



EXPLANATORY 



(a) It requires 0.75% starch to make 
the precipitated casein finer. 

(b) One hour completely dextrinizes 
the Starch. 

(c) In case physicians do not wish to 
sub-divide the proteids, the words 
"Whey" and "Casein" may be erased. 

(d) Twenty minutes renders the mix- 
ture decidedly bitter. 

(e) It requires 0.20% of the milk and 
cream used in modifying to facilitate 
the digestion of the proteids; i. e., the 
formation of a soft curd. 0.40% to pre- 
vent the action of rennet; i. e., the 
formation of tough curd. 

(f) It requires 0.68% of the milk and 
cream used in modifying to favor the 
digestion of the proteids. 1.70% of the 
amount of milk and cream used sus- 
pends all action on the proteids in the 
stomach. 0.17% of the total mixture 
gives a mild alkaline food. 



(g) It requires 20% of the milk and 
cream used in modifying to favor the 
digestion of the proteids. 50% of the 
amount of milk and cream used sus- 
pends all action on the proteids in the 
stomach. 5% of the total mixture gives 
a mild alkaline food. 

(h) Percentage figures represent the 
per cent of Lactic Acid attained when 
the food is removed from the thermo- 
stat. When the Lactic Acid Bacillus is 
used to facilitate digestion of the pro- 
teids, this is the final acidity, as the 
process is stopped by heat at this point. 
When the Lactic Acid Bacillus is used 
to inhibit the growth of saprophytes, 
the acidity may subsequently increase to 
a variable degree, as the bacilli are left 
alive. 0.25% Lactic Acid just curdles 
milk. 0.50% gives thick curdled milk. 
0.75% separates into curds and whey. 



228 THE PRESCRIBING OF MODIFIED MILK 

they are not great enough to disturb the digestion or to interfere 
with the nutrition and development of babies fed upon them. 
The average infant fortunately does not notice small variations in 
the composition of an artificial food any more than it does similar 
variations in the composition of breast-milk. Extreme accuracy 
is necessary only in exceptional cases. In general, therefore, the 
modifications of milk prepared at home are sufficiently accurate 
for all practical purposes and it is rarely necessary on this account 
to have recourse to a milk laboratory. When practicable, it is, 
however, much easier, and in most instances will be found more 
satisfactory, to have modified milk prepared at a laboratory 
rather than at home. 

It is often said that the calculation of the formulae for the prep- 
aration of modified milk at home is too complicated for the average 
physician to carry out and that it requires more time than the busy 
practitioner can give to it. These statements are distinctly not 
true. There is nothing about the calculation of formulae suffi- 
ciently accurate for practical purposes which cannot be understood 
by anyone with even an elementary knowledge of arithmetic. 
If a physician cannot understand the principles involved, there 
must have been some mistake made when his degree was granted. 
There is no more reason why a physician should not take the time 
to calculate a proper modification of milk for a baby than why he 
should not take the time to sterilize his hands before an abdominal 
operation. He is equally negligent in either case, if he does not. 
As a matter of fact, however, it requires but little time to calculate 
a formula, if the physician knows how to do it. Five or, at the 
most, ten minutes are amply sufficient. 

It is also not infrequently said that the procedures involved in 
the preparation of modifications of milk in the home are too compli- 
cated for the ordinary mother or nurse maid to comprehend and 
carry out. This statement is also untrue. There is nothing about 
the preparation of modified milk in the home which any woman 
of average intelligence cannot understand and do, provided it is 
properly explained to her. The trouble is not with the women, but 
with the physicians who, either through ignorance or carelessness, 
neglect to explain the details of the preparation of the food to them. 

In prescribing for modified milk to be prepared in the home it is 
necessary to determine not only what food shall be given to the 
baby, but also how this food shall be prepared. It is of great 
importance, in the first place, to be sure that the milk which is to 
be used is a clean milk. It is impossible to make a good food from 
dirty milk, no matter how much it is modified. 



THE PRESCRIBING OF MODIFIED MILK 229 

It is also of considerable importance to employ milk which is 
reasonably constant in its composition. This is best done by using 
certified milk. Modifications prepared from ordinary milk, pro- 
vided it is not from Jersey cows or similar breeds, are, however, in 
most instances sufficiently accurate in places where there is a 
legal standard for milk. When there is a doubt as to the composi- 
tion of the milk, it is not a difficult matter to determine it approx- 
imately. 

The fat content of milk can be accurately determined in a few 
minutes with one of the small hand Babcock milk testers. A very- 
satisfactory two-bottle machine, The " Facile Jr.," is made by 
D. H. Burrell and Co., of Little Falls, N. Y. The price with 
bottles, pipette and measuring glasses is $4.50. It is important in 
making this test to use sulphuric acid of a specific gravity of from 
1.82 to 1.83 at 60° F. The total solids can be easily determined in 
a few minutes with a lactothermometer and a Richmond "Milk 
Slide Rule. " These, with directions for their use, may also be pro- 
cured of D. H. Burrell and Co., the price of the lactothermometer 
being from $1.00 to $1.50, and that of the Richmond "rule" $2.50. 
The percentage of fat and the total solids being known and the 
percentages of the ash and sugar being fairly constant, the per- 
centage of the protein can be approximately determined with rea- 
sonable accuracy by subtracting the sum of the percentage of fat 
and the estimated percentages of the sugar and ash from the per- 
centage of the total solids. The percentage of casein can be readily 
determined in from fifteen to twenty minutes by the volumetric 
method of Van Slyke and Bosworth, if more accurate results 
are desired. 1 Multiplying the percentage of casein by 1.4 gives 
the percentage of the total protein accurately enough for practical 
purposes. 

Composition of Materials used in the Home Modification of 
Milk. — It being impossible, except in rare instances, to analyze the 
milk and cream used in the preparation of modified milk in the 
home, it is necessary to adopt certain arbitrary standards as to the 
composition of these substances. It must be remembered that any 
form of milk containing more than 4% of fat is technically cream. 
It is wrong, therefore, to think and speak of cream as a definite 
entity, without qualification. It is more correct to think of creams, 
with the fat content always specified. The following figures 
(Table 43) as to the composition of the various creams, whole 
milk, skimmed milk and whey are approximately correct: 

1 New York Medical Journal, 1909, xc, 542. 



230 



THE PRESCRIBING OF MODIFIED MILK 



TABLE 43 



Whole milk 

7% cream 

10% cream 

16% cream 

32% cream 

Skimmed milk 

Separated milk ("fat free") 
Whey 



Fat 



4.00 

7.00 

10.00 

16.00 

32.00 

1.00 

0.25 

0.25 



Milk sugar 



4.50 
4.45 
4.40 
4.20 
3.40 
5.00 
5.00 
5.00 



Protein 



3.50 
3.40 
3.25 
3.05 
2.50 
3.55 
3.65 
0.90 



If milk is allowed to set six hours or longer, the upper sixteen 
ounces of a quart of bottled milk contain 7% and the upper ten 
ounces 10% of fat. The cream layer, that is " gravity cream," 
without regard to how many ounces of it there are on a quart, 
contains about 16% of fat. If the whole milk from which cream is 
obtained contains more than 4% of fat, the cream will contain a 
proportionally larger amount. Ordinary "thick cream," as it is 
called, contains, on the average, 32% of fat. The composition of 
this type of cream is, however, very variable, so variable indeed 
that it is hardly safe to use it in the preparation of modified milk, 
unless the percentage of fat is known. 

Skimmed milk is the milk which is left after the gravity cream 
has been removed by a dipper or by pouring. If some of the upper 
layers of the milk are removed in addition to the cream, the part 
which is left contains less than 1% of fat. Separated ("fat free") 
milk is the milk which is left when the cream has been removed by 
centrifugalization. The whey obtained from separated milk con- 
tains 1% of protein. 

Table 44 copied from Chapin and Pisek, 1 shows the percentage 
of fat in each of the top nine ounces of a quart of bottled milk 
which has set six hours or longer, and the fat content of the 
top ounces, from two ounces to thirty ounces, under the same 
conditions. 

It is evident that "top milk" may mean any number of ounces, 
from one to thirty-one ounces, from a quart. It is also evident that 
the so-called "top milks" are merely creams of varying per- 
centages and that modifications of milk made from "top milks" 
differ in no way from those made from creams except in name. 
Since top milks vary as much in their fat contents as do creams, it is 
evidently just as important in prescribing for the preparation of 



1 Diseases of Children, 1909, p. 138. 



THE PRESCRIBING OF MODIFIED MILK 231 



TABLE 44 
First ounce contains 25 .0% fat 



Second 


1 


Third 


i 


Fourth 


i 


Fifth 


t 


Sixth 


i 


Seventh 


t 


Eighth 


t 


Ninth 


i 


Top 2o 


un 


3 


u 


4 


tt 


5 


it 


6 


tt 


7 


u 


8 


tt 


9 


a 


10 


tt 


12 


tt 


14 


tt 


16 


a 


18 


tt 


20 


tt 


22 


it 


24 


u 


26 


it 


28 


tt 


30 


tt 



,23.0% 
.19.0% 

18.5% 
10.5% 

4.8% 
3.4% 
2.2% 
1.8% 



2 ounces mixed contain 24.0% fat 

" 22.5% " 

« 21.4% " 

" 19.2% " 

" 16.8% " 

" 15.0% " 



13.3% 

11.5% 

10.5% 

9.0% 

7.8% 

■ 7.0% 
6.3% 
5.8% 

. 5.4% 

5.0% 

• 4.7% 

. 4.5% 

■ 4.3% 



modified milk at home to specify exactly what top milk is to be 
used as it is to specify what sort of cream is to be used. 

Method of Calculation of Formulae for the Home Modification 
of Milk. — There are many methods for the calculation of the 
formulae for modifications of milk to be prepared in the home. 
Most of them are inaccurate in that the fat in the skimmed milk is 
disregarded, many of them in that the percentage of protein in the 
cream and skimmed milk is considered to be the same. All of them 
are accurate enough, however, for everyday work. It makes but 
little difference which method is employed, provided that method 
is understood and used correctly. It makes no difference whether 
gravity cream, 10% cream, top milks, skimmed milk or whole 
milk are used in the preparation of the mixtures. Equally good 
results can be obtained with all. The one important thing is that 
the food be calculated in percentages of the various food elements. 
It makes little difference how these elements are obtained. Meth- 
ods which take the fat in the skimmed milk and the differences in 



232 THE PRESCRIBING OF MODIFIED MILK 

the protein content of the various creams and milks into account 
are too complicated for ordinary, clinical use and are, fortunately, 
unnecessary. Those who wish to familiarize themselves with 
these different methods can find them fully described in two 
articles by Westcott. 1 

The writers have found the following method of calculation a 
satisfactory one in their own practice and have found that medical 
students understand it quickly and apply it easily and these are its 
chief recommendations. It is unquestionably inaccurate in many 
ways, as are all simple methods of calculation. It must be remem- 
bered, however, in criticising methods of calculation for their 
inaccuracies, that, if the same method is used consistently, the 
inaccuracies are always similar and that different modifications of 
milk prepared by the same method are accurate relatively to each 
other. That is to say, if a baby who is taking a mixture supposed 
to contain 3.50% of fat, but which really contains 4% of fat, 
shows symptoms of fat indigestion, a reduction of 0.50% in the 
percentage of fat will have the same effect in relieving these 
symptoms, although it is a reduction from 4% to 3.50% instead of 
one from 3.50% to 3%, as it is supposed to be. That is, changes in 
the percentages are correct, even if the original percentages are 
incorrect. 

Gravity cream and skimmed milk are used in this method. The 
gravity cream is estimated to contain 16% of fat and the skimmed 
milk to be fat free. The mixtures, therefore, all contain a some- 
what higher percentage of fat than they are supposed to contain. 
The protein content of both the gravity cream and the skimmed 
milk is calculated to be 3.20%. This percentage is higher than 
that really present in the cream and lower than that in the 
skimmed milk. Numerous analyes, made by us by the Kjeldahl 
method, of the protein content of mixtures prepared in this way 
have shown, however, that the percentage of protein in them is 
not far from what it is calculated to be. They are much more 
nearly correct than would be expected. The percentage of sugar 
is estimated at 4.50 in both the gravity cream and skimmed 
milk. 

It may be well to define what is meant by gravity cream and 
skimmed milk once more before describing the method of calcula- 
tion. By gravity cream is meant all the cream which is visible on 

1 The Scientific Modification of Milk. International Clinics, 1900, Tenth 
Series, iii, 233, and A Method for the Differential Modification of the Proteids 
in Percentage Milk Mixtures. American Journal Medical Sciences, 1901, 
cxxii, 439. 



THE PRESCRIBING OF MODIFIED MILK 233 

milk which has set for six hours or longer. All the cream must be 
removed and the required number of ounces taken from it. If 
there is not enough cream on one bottle, the cream must be re- 
moved from two bottles and mixed. The required number of 
ounces is then taken from the mixture of the two. The cream may- 
be removed with a cream dipper or it may be poured off. The 
results obtained by pouring are not as accurate as those obtained 
by dipping. The same result may be obtained by siphoning off 
the milk below the cream and leaving the cream in the bottle. 
When a cream dipper is used, the first ounce must, of course, be 
removed with a spoon or the milk will be spilled when the dipper is 
introduced. Most bottled milk has been in the bottles many more 
than six hours before it is delivered. When the milk bottle is 
full, the cream rises even during transportation. It is not neces- 
sary, therefore, to wait six hours after the milk is delivered before 
preparing the food, provided the cream line is distinct. 

By skimmed milk is meant what is left after the gravity cream 
has been removed. The percentage of fat in the mixture will be 
more nearly correct if the lowest ounces are used instead of the 
same number of ounces from the whole of the skimmed milk. 

A rounded tablespoonful of milk sugar is considered in this 
method of calculation to weigh one-half an ounce. It will be 
found that this is not far from the true weight. By a rounded 
tablespoonful is meant what is contained in a tablespoon when 
it is dipped into milk sugar and then gently shaken, that is, it is 
rounded, not heaped or level. Every cook knows what is meant by 
this term. The weight of equal quantities of milk sugar and the 
dextrin-maltose mixtures is nearly enough the same for practical 
purposes. 

The estimated composition of the materials used in the prepara-^ 
tion of the mixtures is, therefore, as follows : 

TABLE 45 



Fat 



Milk sugar 



Protein 



Gravity cream . 
Skimmed milk . 
Milk sugar 



16.00% 
0.00% 



4.50% 
4.50% 



3.20% 
3.20% 



1 rounded tablespoonful = % ounce. 



It is necessary, as always, before beginning the calculations as to 
the preparation of the food, to decide what percentages of fat, 
sugar and protein the food is to contain, how much is to be given 
in the twenty-four hours and how much lime water, if any, is to 



234 THE PRESCRIBING OF MODIFIED MILK 

be added. It is usually advisable to make the quantity large 
enough to allow for an extra bottle, so that, if a bottle is broken, 
the baby need not go hungry. 

Suppose that it is desired to prepare thirty-two ounces of a mix- 
ture containing 3% of fat, 6% of milk sugar and 2% of protein, 
with lime water enough to equal 25% of the milk and cream in the 
mixture. The fat in the food must be derived from the cream, 
because it is the only substance containing fat to be used in the 
preparation of the food. If the food was composed entirely of 
gravity cream it would contain 16% of fat. Since it is to contain 
but 3% of fat, it is evident that only three-sixteenths of the mix- 
ture must be gravity cream, ys of thirty-two ounces is six ounces. 
Six ounces of gravity cream will, therefore, provide the 3% of fat- 
desired in the mixture. 

The gravity cream contains protein as well as fat. There are 
six ounces of gravity cream in the thirty-two-ounce mixture. The 
protein content of gravity cream is 3.20%. The protein content of 
a thirty-two-ounce mixture containing six ounces of gravity cream 
is evidently -^ of 3.20%, or 0.60%. Two per cent of protein is, 
however, desired in the mixture. The gravity cream has provided 
only 0.60%. One and forty hundredths per cent of protein, the 
difference between the percentage of protein desired and that fur- 
nished by the gravity cream, must be obtained in some other way. 
It must be obtained, moreover, from some substance which does 
not contain fat. Skimmed milk is such a substance. Skimmed 
milk contains 3.20% of protein. In order to get 1.40% of protein 
in the mixture by the use of skimmed milk, it is evident that 
-J 4J- of the mixture must be skimmed milk. |4Sy of thirty-two 
ounces is fourteen ounces. Fourteen ounces of skimmed milk will, 
therefore, provide the additional 1.40% of protein desired. 

Both gravity cream and skimmed milk contain 4.50% of milk 
sugar. Twenty ounces of gravity cream and skimmed milk are 
required to furnish the desired percentages of fat and protein. 
These twenty ounces in a thirty-two-ounce mixture must add f § 
of 4.50% of sugar to the mixture. Twenty thirty-seconds of 4^, or 
14 of | = -6^> or practically 3% of milk sugar. It is, however, 
desired to have 6% of milk sugar in the mixture. That is, 3% more 
of milk sugar is required. This additional sugar must be added in 
the form of dry milk sugar. Three per cent of thirty-two ounces is 
T fo of thirty-two. This will give the amount of sugar desired in 
ounces. The sugar is to be measured in rounded tablespoonfuls, 
or half ounces. If the figures given above are multiplied by two, 
the result will be the number of rounded tablespoonfuls needed. 



THE PRESCRIBING OF MODIFIED MILK 



235 



That is, T J ff of 32 x 2 = y£ grounded tablespoonfuls, or for all prac- 
tical purposes, two rounded tablespoonfuls. 

It is also desired to have an amount of lime water in the mixture 
equal to 25% of the cream and milk in the mixture. There are 
twenty ounces of cream and milk in the mixture. Twenty-five per 
cent of twenty ounces is five ounces. Five ounces of lime water 
must, therefore, be added. The total quantity of the mixture is to 
be thirty-two ounces. The mixture is to contain six ounces of grav- 
ity cream, fourteen ounces of skimmed milk and five ounces of lime 
water, that is, twenty-five ounces. The milk sugar goes into solu- 
tion and, therefore, does not add to this quantity. The difference 
between thirty-two ounces and twenty-five ounces is seven ounces. 
Seven ounces of water must, therefore, be added to make up the 
quantity desired. The following table shows the results of the 
steps just described: 





TABLE 


46 








Ounces 


Fat 


Sugar 


Protein 


Gravity cream 

Skimmed milk 

Milk sugar 


6 
14 

2 rounded table- 
spoonfuls 
5 

7 


3.00 


J3.00 
3.00 


0.60 
1.40 


Lime water 




Water 










32 


3.00 


6.00 


2.00 



The milk sugar should be dissolved in the seven ounces of hot 
water. The water should be allowed to cool and then be mixed 
with the other ingredients. 

Mixtures containing Starch. — It is as important to have the per- 
centage of starch in the food accurate as it is to have those of the 
fat, sugar and protein. Starch is usually added in the form of the 
cereal waters. The strength of the cereal water which is to be used 
in the preparation of the food must be known, therefore, in order 
to get the desired percentage of starch in the mixture. 

Two rounded teaspoonfuls of barley or oat flour to the pint of 
water have been found by analysis to give a 1.50% decoction of 
starch, while four rounded teaspoonfuls to the pint of water give a 
3% decoction. The flour should be mixed with a small amount of 
water, after which the remainder of the water is added. The mix- 
ture is then boiled for twenty minutes, after which, as some of the 
water has boiled away, enough hot water is added to make up the 



236 THE PRESCRIBING OF MODIFIED MILK 

original pint. It should then be strained through several thick- 
nesses of cheesecloth. It should be cooled before being mixed with 
the milk and cream. 

If it is desired to have 0.75% of starch in a mixture and a cereal 
water containing 1.50% of starch is to be used, it is evident that 
one-half of the mixture must be made up of the cereal water. If a 
3% cereal water is used, one-quarter of the mixture will be re- 
quired to give 0.75% of starch. Suppose that it is desired to have 
0.75% of barley starch in the mixture which has just been calcu- 
lated. In order to get 0.75% of starch in a thirty-two-ounce mix- 
ture, using 1.50% barley water, it will be necessary to use T :J| of 
thirty-two ounces, or sixteen ounces. The mixture already con- 
tains twenty-five ounces of gravity cream, skimmed milk and lime 
water, leaving room for only seven ounces of barley water. It is 
plain, therefore, that it is impossible to have 0.75% of starch in the 
mixture, if 1.50% barley water is used. If 3.00% barley water is 
used, JrfJ of thirty-two ounces, or eight ounces will be required. 
There is room for only seven ounces. The difference in the per- 
centage of starch added when seven or eight ounces are added is 
only 0.10%, which is a negligible amount. Seven ounces of 3.00% 
barley water will, therefore, be sufficient. 

If preferred, the amount of starch to be added to a mixture to 
give any percentage required of starch in the mixture may be cal- 
culated directly. Suppose, for example, it is desired to have 0.75% 
of barley starch in a forty-eight-ounce mixture. Two rounded 
teaspoonfuls of barley flour to the pint gives 1.50% of starch in 
the mixture. One rounded teaspoonful to the pint gives 0.75% 
of starch in the mixture. There are three pints in forty-eight 
ounces. Therefore three rounded teaspoonfuls of flour will be re- 
quired to give 0.75% of starch in forty-eight ounces. This amount 
of barley flour should be cooked in the number of ounces of water 
in the mixture and then mixed with the gravity cream and skimmed 
milk. 

Whey Mixtures. — It is impossible to make mixtures containing 
a high percentage of whey protein with a low percentage of casein, 
provided they contain more than 1 or 2% of fat, if gravity cream 
is used in the preparation of the food, as it usually is in the home. 
The reason of this is that the gravity cream which it is necessary 
to use in order to get the desired percentages of fat contains a con- 
siderable amount of protein and by its bulk diminishes the amount 
of whey and consequently the amount of whey protein which can 
be added. It is usually desired, when whey protein is prescribed, 
to have as much of it in a mixture as is possible. For practical pur- 



THE PRESCRIBING OF MODIFIED MILK 237 

poses, therefore, when whey mixtures are prepared in the home 
with gravity cream, the amount of gravity cream required to give 
the desired percentage of fat is calculated and the rest of the mix- 
ture made up with whey, the amount of whey protein added being 
determined later. Smaller percentages of whey protein can be 
added, of course, if desired. 

Suppose that it is desired to give a baby a twenty-four-ounce 
mixture containing 3% of fat and 6% of sugar, with lime water 
10% of the cream in the mixture. yq of twenty-four ounces is four 
and one-half ounces. Four and one-half ounces of gravity cream 
will, therefore, be required. This will put V*~ of 3.20%, or 0.60%, 
of protein in the mixture. This protein is chiefly in the form of ca- 
sein. Ten per cent of four and one-half ounces is nearly one-half an 
ounce. One-half an ounce of lime water must, therefore, be added. 
It is evident that there is room for nineteen ounces of whey in the 
mixture, the difference between twenty-four and 4J^ + /4, being 
nineteen. The composition of whey for practical work in the home 
modification of milk may be calculated to be 0.90%. || of 0.90% 
of whey protein gives 0.70 of whey protein, which is the amount 
added by the whey. 





Fat 


Milk sugar 


Whey protein 


Whey 


0.00 


4.50 


0.90 







Both the gravity cream and the whey contain 4.50% of milk 
sugar. There being but one-half ounce of lime water in the whole 
mixture, it already contains approximately 4.50% of milk sugar. 
It being desired to have 6% of milk sugar in the mixture, 1.50% 
more must be added in the form of dry milk sugar. - T i" 7 2 - of 
24 x 2 = 0.72 of a rounded tablespoonful. A level tablespoonful 
of milk sugar will, therefore, just about make up the required 
percentage of sugar. 

The mixture contains 3% of fat, 6% of sugar, 0.70% of whey 
protein and 0.60% of casein. It is evident, therefore, that, if grav- 
ity cream is used, it is impossible to get less than 0.60% of casein 
in the mixture with 3% of fat, or less than 0.80 of casein with 4% of 
fat. The percentage of whey protein in the mixture is really some- 
what higher and that of the casein somewhat lower than has been 
calculated, because about one-quarter of the protein furnished by 
the cream is in the form of whey protein. It is not necessary for 
every-day work, however, to take these small differences into con- 
sideration. 



238 THE PRESCRIBING OF MODIFIED MILK 

Higher percentages of whey protein and lower percentages of 
casein can be obtained with given percentages of fat, if creams 
containing higher percentages of fat are used. It is possible, for 
example, even in the home, to get cream containing 24% of fat by 
taking only the top two ounces off of the quart. 

It is also possible to have any percentage of casein desired with a 
given percentage of fat by using skimmed milk in the mixture. The 
amount of whey protein which can be put in the mixture is, of 
course, correspondingly diminished. When it is desired to work 
off of a whey mixture on to an ordinary mixture without in- 
creasing the total amount of protein, it is best done by gradually 
replacing the whey by skimmed milk and water. One ounce of 
skimmed milk and three ounces of water contain approximately 
the same amount of protein as four ounces of whey. 

Preparation of Whey. — Put a pint of skimmed milk into a clean 
saucepan and heat it until it is lukewarm (not over 100° F.). Take 
off of the stove. Add two teaspoonfuls of essence of pepsin or liq- 
uid rennet, or two junket tablets. Stir just enough to mix. Let 
it stand until firmly jellied. Then break up with a fork until it is 
finely divided. Strain through a linen cloth or several thicknesses 
of cheesecloth. What goes through is whey. If whey is to be mixed 
with cream, milk or skimmed milk, it must be brought to 150° F. 
in order to kill the rennin. If whey is not brought to this tempera- 
ture before it is added to milk or cream, the rennin in it will cur- 
dle them. It should be cooled before being mixed with cream or 
milk. 

The Determination of Percentages in Mixtures. — It is often of 
great importance to find out just what a baby has been taking in 
order to know how to change the food, if it is not agreeing with it. 
To do this it is necessary to determine the percentages of the dif- 
ferent elements in the food. This is not a difficult matter. Sup- 
pose that a baby is taking a food made up as follows: 

Gravity cream 12 ounces 

Skimmed milk 18 ounces 

Lime water 6 ounces 

Barley water 12 ounces 

Milk sugar 4 rounded tablespoonfuls 

The barley water is made with two teaspoonfuls of barley flour 
in a pint of water. 

The total quantity of the mixture is forty-eight ounces. Gravity 
cream contains 16% of fat. Twelve ounces of gravity cream in a 
forty-eight-ounce mixture will give, therefore, 12/48 of 16% of fat, 



CALORIC VALUES 239 

or 4% of fat. Both gravity cream and skimmed milk contain 
3.20% of protein. There are thirty ounces of gravity cream and 
skimmed milk in the mixture. Thirty ounces in a forty-eight- 
ounce mixture will give 30/48 of 3.20% of protein, or 2.00% of pro- 
tein. Both the gravity cream and the skimmed milk also contain 
4.50% of sugar. Thirty ounces of gravity cream and skimmed milk 
in a forty-eight-ounce mixture will, therefore, furnish 30/48 of 4J/£, 
which is the same as 30/48 of 9/2, or almost 3.00% of milk sugar. 
Four rounded tablespoonfuls of milk sugar are equal to two ounces. 
Two ounces of sugar in a forty-eight-ounce mixture is equal to 2/48 
of 100%, or 4%. The total percentage of sugar is, therefore, 
7%. Two teaspoonfuls of barley flour in a pint of water makes 
a 1.50% decoction of starch. Twelve ounces of barley water of 
this strength in a forty-eight-ounce mixture will give 12/48 of 1.50% 
or about 0.35% of starch. There are six ounces of lime water in the 
mixture and thirty ounces of gravity cream and skimmed milk; 
6/30 of 100% is 20%. The lime water in the mixture is, therefore, 
20% of the milk and cream. The mixture thus contains 4% of fat, 
7% of milk sugar, 2% of protein and 0.35% of starch, while the 
lime water is present in the proportion of 20% of the cream and 
milk. 

Method of Deternuning the Caloric Value of Mixtures of Modi- 
fied Milk. — The method detailed below is longer than some of the 
other methods in common use. It is more accurate than many of 
them, however, and has this in its favor, namely, it is impossible to 
carry it out without fully understanding what the caloric value of 
food really means. 

Suppose that a baby is taking thirty ounces of a food containing 
4% of fat, 6% of sugar, 2.25% of protein and 0.75% of starch. 
Thirty ounces is equal to 900 cubic centimeters. Four per cent fat 
means that there are 4 grams of fat in each 100 cubic centimeters 
of food. The baby is taking 900 cubic centimeters of food, that is, 
it is taking nine times the amount of fat in 100 cubic centimeters of 
food, or nine times 4 grams, which is 36 grams. The caloric value 
of 1 gram of fat is 9.3 calories. Thirty-six grams of fat will give 
thirty-six times 9.3 calories, which is equal to 334.8 calories. 

The caloric value of sugar, starch and protein is the same, each 
gram yielding 4.1 calories. 1 The caloric value of these elements 
can, therefore, be calculated at the same time, There are 6 grams 
of sugar, 2.25 grams of protein and 0.75 grams of starch, or a total 
of 9 grams in each 100 cubic centimeters of the food. There are, 
therefore, nine times 9 grams, or 81 grams, in 900 cubic centimeters 
1 The caloric value of a gram of milk sugar is in reality 3.78 calories. 



240 CALORIC VALUES 

of food. One gram is equivalent to 4.1 calories. Eighty-one grams 
provide 81 x 4.1 calories or 332.1 calories. The sum of the 334.4 
calories furnished by the fat and the 332.1 calories furnished by 
the sugar, starch and protein is 666.9 calories, which is, therefore, 
the caloric value of the mixture. 

The caloric value of the food is of importance only in its relation 
to the weight of the baby. Suppose that the baby who has been 
taking the above food weighs eleven pounds. Dividing the num- 
ber of calories in the food by the weight gives the number of cal- 
ories which it gets per unit of weight. That is, 666.9 calories di- 
vided by eleven gives 60 calories, which is the number of calories 
which it is getting per pound of weight. 

A kilogram is equal to two and two-tenths pounds. Eleven 
pounds is equal, therefore, to 5 kilograms. Dividing 666.9 calories 
by five gives the number of calories which the baby is getting per 
kilogram of body weight, that is, 133 calories. 

A simple, but less accurate, method of calculating the caloric 
value of a modified milk mixture is that recommended by Fraley 
(Archives of Pediatrics, 1912, xxix, 123). Letting F = the per- 
centage of fat, S the percentage of sugar and starch, P the per- 
centage of protein and Q the total quantity of food, then 

2F+P+SxlKQ = calories. 

This formula always gives the caloric value a little lower 
than it really is. It gives, for example, 637 calories as the 
value of the food just calculated above, when the real value 
is 666.9 calories. 

Still another method, which is also accurate, is that recom- 
mended by Bowditch (Jour. A. M. A., 1909, liii, 1265). The caloric 
value of a food is very easily calculated by this method by the use 
of a table. 

The Method of Determining the Protein Content of Mixtures of 
Modified Milk. — It is very easy to determine the protein content 
of a food by using the same principle employed in estimating the ca- 
loric value. Suppose that a baby weighing fifteen pounds is taking 
forty-eight ounces of a food containing 2.50% of protein. Forty- 
eight ounces is equal to 1440 c. c. There are 2.5 grams of protein 
in each 100 c. c. of food, or 14.4 x 2.5 grams in the whole amount. 
14.4 x 2.5 grams = 36 grams. The baby weighs fifteen pounds. 
It gets, therefore, 2.4 grams of protein per pound of body weight 
in this food. Fifteen pounds is 6.8 kilograms. Dividing 36 grams 
by 6.8 gives 5.3 grams, which is the amount of protein which the 
baby gets per kilogram of weight from this food. 



PANCREATIZATION 241 

The Pancreatization of Modified Milk. — Pancreatized milk pre- 
pared with "Peptogenic Milk Powder" is often given to infants. 
The objection to the use of pancreatized milk prepared in this way 
is that, if the directions as to the preparation of the food are fol- 
lowed, it is a routine food and not susceptible of variation to meet 
the needs of the individual infant at the given time. It is far bet- 
ter to make a mixture to meet the indications in the given case and 
then to pancreatize it by the addition of one of the " peptonizing" 
powders or tablets. In this way the advantages of a food suited 
to the needs of the baby and of predigestion of the food are both 
retained. 

The food may be heated at "blood heat," not over 115° F., for 
ten minutes and then brought quickly to a boil. The ferments are 
destroyed by the boiling and the food will, therefore, not become 
bitter. It is better to add a part of the contents of a " peptonizing " 
tube or part of a tablet to each feeding just before it is to be used. 
The feeding is then heated for from ten minutes to fifteen minutes 
at blood heat, or from 100° F. to 115° F., being allowed to drop to 
100° F. toward the end of this time, and immediately given to the 
baby. The advantage of this method is that the ferments are 
still active when the food is ingested and will continue to act until 
the reaction of the stomach contents becomes acid. The contents 
of a "peptonizing" tube, or a "peptonizing" tablet, are usually 
intended for the pancreatization of a pint of milk. The proportion 
of milk in each feeding being known, it is a simple matter to cal- 
culate how much of the powder or tablet to add. "Peptonized 
milk" prepared by the so-called "cold process" is, of course, not 
predigested at all, because the pancreatic enzymes do not act in the 
cold. The only opportunity which they have to act, when milk is 
prepared by this process, is after they are taken into the stomach. 
Their action ceases, however, when the reaction of the stomach 
contents becomes acid. 



PROPRIETARY FOODS 

The first thing to be remembered when considering the propri- 
etary foods is that there are only certain food elements, namely, 
fat, carbohydrates, protein and mineral matters. There can, there- 
fore, be nothing in the proprietary foods except these elements. 
All of the elements are easy to procure and can be put into modi- 
fied milk in any form and in any amount desired. 

It is often said that a certain baby did not do well on modified 
milk but at once began to thrive when given a certain proprietary 



242 PROPRIETARY FOODS 

food. Such a statement is undoubtedly true. This does not 
show, however, that this proprietary food is better than modified 
milk. It merely shows that the combination of the different food 
elements in this food was the one suitable for this baby. There was 
nothing in the proprietary food which could not have equally well 
been put in a modified milk. The difficulty with modified milk was 
that the person who prescribed it did not understand or know how 
to meet the indications in the given case. If he had, the baby 
would have thrived as well on modified milk as on the proprietary 
food. It is noteworthy in this connection that while much is said 
in praise of a given food when a baby does well on it, nothing is 
said about all the other proprietary foods upon which it did not do 
well. 

A great objection to proprietary foods is that their use tends to 
develop slip-shod methods on the part of physicians. They get in 
the habit of choosing proprietary foods at random or of using some 
food constantly, because they have seen a number of babies thrive 
on it, instead of thinking for themselves and endeavoring to pre- 
scribe a milk modification to fit the needs of the individual baby at 
the given time. Another objection to the proprietary foods is 
that, being led by the advertisements of the manufacturers of these 
foods to believe that the artificial feeding of infants is a very sim- 
ple matter, parents attempt to feed their own babies on such foods 
instead of employing a physician to prescribe the feeding. The 
results are often unfortunate, to say the least. 

A still further objection to proprietary foods is their cost. It is 
a self-evident proposition that the people who buy the foods have 
to pay for the manufacture and advertising of the food, as well as a 
profit to the manufacturer and various middlemen, neither the 
manufacturer nor the middlemen being in business "for their 
health." This expense is unnecessary, because modifications of 
milk containing everything which is in these proprietary foods can 
be readily prepared from simple materials in the home. The com- 
position of some of the proprietary foods in most common use in 
this country is given in the table on pages 244-245. 

It is noteworthy that these proprietary foods can be divided into 
four main groups. I. The condensed milks, sweetened or un- 
sweetened. II. The malted foods, in which the whole, or a con- 
siderable part, of the carbohydrates is in the form of maltose and 
the various dextrins. III. The foods in which there is a con- 
siderable proportion of starch in addition to the soluble carbohy- 
drates. IV. The foods which are almost entirely composed of 
starch. The different groups are worthy of separate consideration. 



PROPRIETARY FOODS 243 

I. The Condensed Milks. — Condensed milk is almost never 
given undiluted. The customary dilution is one part of con- 
densed milk to nine parts of water. This dilution gives a mixture, 
if Eagle Brand Condensed Milk is used, containing 0.96% of fat, 
5.49% of sugar and 0.80% of protein. This analysis explains why 
a baby that has a disturbance of digestion from overfeeding will 
do well on condensed milk. It will do equally well on a modified 
fresh milk containing the same percentages. It is also evident, 
from this analysis, that a very large amount of this food must be 
taken to cover the caloric and protein needs of a baby. The rela- 
tion between the carbohydrates and fat is not a proper one for the 
normal well infant and the protein is too low. The caloric value of 
the food is even lower, when the unsweetened condensed milks are 
used. Condensed milk is, moreover, not a uniformly sterile prod- 
uct, as is commonly supposed. Some specimens are sterile, but 
many are not. The bacterial content of some of them is as high as 
10,000,000 per cubic centimeter. 1 

n. The Malted Foods. — The chief reasons that foods of this 
class agree with so many babies are that the carbohydrates are in 
the form of maltose and dextrins and that the dextrins, by their 
colloidal action, favor the digestion of protein. Mellin's Food and 
Mead's Dextri-Maltose are examples of this class. So also is 
Horlick's Malted Milk which, however, differs from those first men- 
tioned, as do also Laibose and Allenbury's Foods, No. 1 and No. 2, 
in that they also contain dried milk in addition to malt sugar and 
dextrins. Those that contain dried milk are intended to be mixed 
with water. When so mixed, they are, in spite of the dried milk 
which they contain, deficient, in that the fat and protein content of 
the mixture is too low. When those that do not contain dried milk 
are mixed with water, the mixtures contain practically no fat and 
but little protein. When mixed with milk or cream, the result is a 
modified milk with the sugar in the form of maltose and the dextrins. 
Such modified milks agree when for any reason milk sugar is con- 
traindicated and maltose and the dextrins are needed. It is inad- 
visable, however, to use these foods according to the directions 
which come with them, because, if this is done, the feeding becomes 
routine and the food is not fitted to the individual baby. It is far 
better to modify the milk to fit the needs of the special infant and 
then, if milk sugar is contraindicated, to add one of these combina- 
tions of maltose and the dextrins to the mixture in its place. Which 
food is chosen will depend on the relative proportions of maltose 
and the dextrins which are desired. The same result may be 

1 Jordan and Mott: American Journal of Public Hygiene, 1910, xx, 391. 



244 



PROPRIETARY FOODS 



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246 



PROPRIETARY FOODS 



obtained by adding a cereal gruel and then dextrinizing the 
food. 

m. The Sugary and Starchy Foods.— Examples of the foods 
which contain considerable amounts of starch in addition to 
various combinations of the various sugars are Eskay's Albumen- 
ized Food, Nestte's Food and "AllenburyV Food No. 3. The 
fat content of the foods of this class is, as a rule, almost infinites- 
imal. When diluted with water they amount to but little more 
than a starch and sugar mixture. When mixed with some form 
of milk they correspond to a modified milk prepared with a cereal 
diluent. 

IV. The Starchy Foods. — Imperial Granum and Ridge's Food 
are striking examples of the starchy foods, or rather of the starch 
foods. The composition of these two foods is almost identical. 
The following comparison of the analyses of Imperial Granum and 
ordinary wheat flour is interesting and instructive (Table 48): 



TABLE 48 



Fat 



Sugar 



Protein 



Starch 



Ash 



Imperial Granum 
Wheat flour 2 



1.04 
1.00 



1.80 



( dextrose . 42 



0.00 



^dextrins 1.38 



14.00 
11.40 



73.54 

75.10 (total 
carbohy- 
drates) 



0.39 
0.50 



It is evident that the sum of the sugars and starch in Imperial 
Granum is essentially the same as the total carbohydrate content 
of wheat flour. Heating wheat flour will change a small per- 
centage of the starch into dextrin and dextrose. It would seem 
cheaper for people to bake their own flour than to pay someone 
else to do it for them, even if they do put it up in a box and give it 
another name. 



THE FEEDING OF INFANTS AFTER WEANING AND DURING THE 
SECOND YEAR 

The average baby that has done well, whether it has been fed on 
the breast or artificially, will be taking, when it is about ten 
months old, a mixture of whole milk and barley water. It will be 
taking five feedings at three-hour intervals, beginning at six in the 

1 Analysis given by Holt. Diseases of Infancy and Childhood, 1911, p. 162. 

2 Chemical Composition of American Food Materials. Atwater and Bryant. 
Bulletin No. 28, U. S. Department of Agriculture. 



FEEDING OF OLDER CHILDREN 247 

morning and ending at six at night. If it has shown a tendency to 
constipation, it will probably be taking some orange juice. 

It may be remarked here, parenthetically, that orange juice is 
not a necessary part of a baby's diet, as many people suppose. It is 
advisable to give it, if the food is pasteurized or boiled, in order to 
guard against the possible development of scurvy. It is also useful, 
if there is a tendency to constipation. It will, moreover, sometimes 
restore a failing appetite. In such cases, however, it is probable 
that the loss of appetite is an early symptom of scurvy. It is wiser 
to give it for definite indications than to use it as a routine measure, 
although it probably does no harm in most instances, even if it is 
not indicated. The best time to give orange juice is one hour 
before a feeding, when the stomach is comparatively empty. It is 
less likely to disturb the digestion when given at this time. It is 
rarely advisable to give more than two tablespoonfuls to a young 
baby. The whole amount for the day should be given at one time. 
It may be diluted with water and sweetened with cane sugar if 
desired. 

The simple cereals should be begun about this time. The most 
easily digestible are barley jelly, oat jelly and farina. The barley 
jelly is made from barley flour, the oat jelly from oat flour or oat- 
meal thoroughly cooked and strained. Two or three rounded 
tablespoonfuls of flour to a pint of water will make a jelly. It 
should be cooked at least an hour. When oatmeal is used it should 
be cooked at least four hours. All cereals which are given to 
infants and children must be thoroughly cooked. Even the simple 
ones should be cooked several hours, in spite of the fact that the 
directions on the package may state that fifteen to twenty minutes 
is sufficient. The most satisfactory way of cooking them is in a 
"fireless cooker." 

In beginning to feed cereals, they should be given at the begin- 
ning of the 9 A. M. and 6 P. M. feedings. Some of the baby's 
mixture should be put on them, never cream or top milk. They 
should be salted, but no sugar should be used. If babies begin to 
eat cereals without sugar, they learn to like them in that way and, 
as they grow older, do not expect to have them or other foods 
smothered in sugar. The chances of the development of a sugar 
indigestion in the future are thus much diminished. It is well to 
begin with a level tablespoonful of cereal, increasing the amount as 
necessary. 

It is usually wiser to wait a few weeks after beginning to give 
cereals, before giving beef juice or broth. The most satisfactory 
form of beef juice is the freshly prepared beef juice. This is made 



248 FEEDING OF OLDER CHILDREN 

by half-broiling a piece of round steak. The steak should then be 
cut into small pieces and the juice squeezed out with a beef press 
or a lemon squeezer. Beef juice prepared in this way contains 
about 0.60% of fat and 2.90% of protein, with a considerable 
amount of extractive matters. Dish gravy, as it is called, is not 
the same thing. It contains a large amount of cooked fat and is 
often highly indigestible. The various manufactured beef juices, 
meat extracts and similar preparations are not as good as the ex- 
pressed beef juice and should be used only when it is impossible to 
obtain fresh beef juice. 1 Beef juice may be given plain or diluted 
with water. It should be salted to taste. It is wiser to begin 
with one teaspoonful, gradually increasing the amount to six 
teaspoonfuls, or one ounce. Babies should never be given more 
than two ounces of beef juice, even in their second year. Beef juice 
is liable to disturb the digestion of some babies and not infrequently 
makes other babies nervous and sleepless. It is always well, there- 
fore, to warn mothers of this possibility when beef juice is first 
given. The best time to give beef juice is at the beginning of 
the noon feeding. 

Mutton broth and chicken broth must be very carefully pre- 
pared. The fat must be entirely skimmed off and the broth should 
be thick enough to form a jelly when cold. Two ounces should 
be given in the beginning and this amount increased to four ounces 
later. The broth should also be given at the beginning of the noon 
feeding, beef juice being given one day, broth the next, and so on. 
It must be remembered that the nutritive value of broth is prac- 
tically nil. The broth serves merely as a vehicle for other food and 
as a stimulant to the appetite. 

It is well to begin to give breadcrumbs and zwiebach in the broth 
and beef juice in the course of a few weeks. At the same time the 
baby may be given bread or zwiebach "in its hand" in order that 
it may learn how to eat. 

It is usually possible to leave out the cereal diluent when the 
baby is a year old and give plain milk. In many instances, how- 
ever, it is advisable to continue to give an ounce of barley jelly or 
oat jelly in each feeding until the baby is one and one-half years 
old. The variety of cereals may be increased by the addition of 
Cream of Wheat, Ralston and rice when the baby is a year old. 
At about fourteen months.it may have milk toast and bread and 
milk. If desired, a part of the milk may be given in the form of 

*See Bull. No. 114, Bureau of Chemistry, U. S. Dept. of Agriculture, 
" Meat Extracts and Similar Preparations, and Jour. A. M. A., 1909, liii, 
1754, "Meat and Beef Juices." 



FEEDING OF OLDER CHILDREN 249 

junket. If the baby is constipated, prune juice and pulp and the 
inside of baked apples may be added at this time or even earlier. 
Plain white crackers, such as soda crackers, Uneeda Biscuits or 
pilot wafers may also be given, either plain or in the form of cracker 
toast. 

It is wiser, in general, not to begin to give eggs until babies are 
about eighteen months old. Many infants are poisoned by eggs. 
It is always advisable, therefore, to begin eggs very cautiously. 
Eggs should be given at first either soft boiled for about two min- 
utes, or coddled for about four minutes. If eggs do not disagree, 
the baby may be given an egg every other day, and by the time 
it is two years old, an egg daily. This may be given in the morning 
or at noon in place of the broth and beef juice. At one and one- 
half years, baked potato, plain boiled macaroni, rice and Wheat 
Germ may be given. Baked custard, plain blanc mange and plain 
boiled tapioca may also be given as desserts, if desired. There is 
no objection at this time to putting butter on the bread. 

This dietary is sufficient until the baby is nearly two years old, 
when meat may be begun: The most easily digestible forms of 
meat are the white meat of chicken, mutton and lamb chop and 
scraped beef. A reasonable dietary for a baby of two years is whole 
milk, butter, mutton broth, chicken broth, beef juice, soft boiled 
eggs, coddled eggs, dropped eggs, white meat of chicken, lamb 
chop, mutton chop, scraped beef, French bread, stale bread, 
toasted bread, whole wheat bread, milk toast, zwiebach, plain 
white crackers, plain Educator crackers, barley jelly, oatmeal, 
Cream of Wheat, Wheat Germ, Ralston, farina, rice, baked potato, 
plain boiled macaroni, orange juice, baked apples, stewed prune 
pulp and juice, junket, baked custard, corn starch pudding, plain 
blanc mange, plain tapioca. It is not advisable, as a rule, to begin 
green vegetables until the baby is two and a half years old. 

In most instances the hours of feeding are changed when the 
baby is from sixteen to eighteen months old. At that time the 
baby gets some milk when it wakes up in the morning. It has its 
breakfast between 8 and 8:30. It gets some more milk, or some 
milk with a piece of bread or a cracker, at 11 or 11:30, before its 
nap. It has its dinner when it wakes up from its nap at 1 :30 or 2, 
and its supper at 5:30. 



CHAPTER XIX 
THE FEEDING OF PREMATURE INFANTS 

All the functions of digestion of premature infants are feeble. 
In a general way, the younger the baby, the feebler are the digest- 
ive powers. Little is known positively as to the absolute or rel- 
ative strength of the various digestive ferments in the premature. 
It is probable, however, that the tolerance for sugar is greater than 
that for fat and protein. The amylolytic function may be present 
at birth, but is relatively undeveloped and should not be called 
upon. It is presumable that the metabolic processes are less active 
in the premature than in the full-term baby and that the utilization 
of the food ingested is, therefore, less complete. There is, however, 
no proof of this supposition. It is a well-known fact that small 
bodies have a greater surface area in proportion to their mass than 
have large bodies. The loss of heat is, therefore, relatively greater 
in proportion to the weight in small than in large bodies. A pre- 
mature infant would, therefore, be expected to require more 
nourishment in proportion to its weight than would the full-term in- 
infant. Another, and perhaps more important, reason why prema- 
ture infants lose heat more rapidly than full-term infants is that 
they have very little fat tissue to act as a blanket to keep the heat 
in. They have, moreover, relatively more " active" tissue, i. e. t 
muscle, than full-term infants and it is apparently the active tis- 
sue which uses up energy and not the fat, which is inactive. The 
difficulties in the way of the successful feeding of premature infants 
are, therefore, obvious. 

All the reasons which prove that human milk is the best food for 
the full-term infant are doubly applicable in the case of the pre- 
mature infant. A premature infant should, therefore, always be 
given breast-milk, if it can possibly be obtained. None but the 
strongest infants or those but little premature should, however, 
be put to the breast. The vast majority of them are too feeble to 
nurse satisfactorily and are unable to bear the handling and expo- 
sure consequent on being put to the breast. Many a premature 
infant has had what few chances it had of survival destroyed in 
this way. The milk should be taken from the breast and fed to 
the baby. There is some difference of opinion as to whether it is 

250 



THE FEEDING OF PREMATURE INFANTS 251 

better for the new-born premature baby to have colostrum or an 
established breast-milk. The evidence on the two sides is incom- 
plete, and the question must be considered as still a mooted one. 
In most instances the baby will naturally get its own mother's 
milk, that is, colostrum, while if it gets another woman's milk, it 
will usually be an established one. For practical purposes, either 
will do. 

There is also considerable difference of opinion as to whether a 
premature baby should be fed within a few hours after birth, 
or whether it should not be fed for twelve hours or for twenty-four 
hours. Those who believe that it should be fed very soon argue 
that it needs nourishment at once, because of its prematurity and 
feebleness, while those who believe in waiting argue that Nature 
shows that a full-term baby should not have food for from twenty- 
four hours to forty-eight hours, since it does not provide food un- 
til this time, that the premature baby needs rest after the fatigue of 
labor more than does the full-term baby, and that it is even less 
able to digest food in the first few hours than the full-term baby. 
On the whole, it is probably best to begin to feed the premature in- 
fant when it is about twelve hours old. 

There is also much difference of opinion as to the intervals at 
which premature babies should be fed. It used to be thought 
that, on account of the small amount taken at a feeding and the 
greater need for food, they should be fed every hour or every one 
and one-half hours. Such frequent feedings do not give the stom- 
ach a chance to empty itself, however, and do not give the baby a 
sufficient opportunity for continued sleep. Ten feedings at inter- 
val of two hours during the day and of four hours during the night 
meet the indications better. The stomach then has time to empty 
itself and the baby is not disturbed too often. Czerny and Keller * 
have for a long time advocated four-hour intervals, and Litzen- 
berg 2 has recently reported some extremely good results in a series 
of fifty cases fed at these intervals. His results show, if nothing 
more, that premature babies can thrive on these longer intervals. 
An additional advantage in these intervals is that if babies do 
thrive as well on them as on the shorter intervals, the care and 
attendance required are much less. 

Caloric Needs. — The reason why the caloric needs of a pre- 
mature baby would be expected to be greater than those of a full- 
term baby have already been mentioned. Experience has shown, 
moreover, that, on the average, premature babies that are thriving 

1 "Ernahrung des gesunden Kindes," p. 685. Quoted by Litzenberg. 
* Amer. Journal of Diseases of Children, 1912, iv, 391. 



252 THE FEEDING OF PREMATURE INFANTS 

do take and require more calories per Kilo of body weight than do 
full-term babies. 1 The average quotient is, however, not as high as 
was formerly supposed. Most premature babies need about 120 
calories per Kilo, but there are many exceptions. Some premature 
babies will thrive and gain on as little as 70 calories per Kilo. No 
attempt should be made to reach 120 calories per Kilo during the 
first few days. Thirty calories per Kilo is as much as it is wise to 
give in the first twenty-four hours of feeding. This amount 
should be gradually increased each day, watching carefully for 
symptoms of indigestion, and diminishing it if these appear. In 
most instances, 120 calories per Kilo can be given in about ten 
days. Very few are able to utilize more than 130 calories per Kilo. 
If this amount is exceeded, they are, in most instances, upset. 

Character of Food. — The first food given should be breast- 
milk diluted with an equal amount of water or a 3% solution of 
milk sugar. The dilution should be diminished from day to day. 
In most instances undiluted breast-milk can be given in from four 
days to a week. If it is impossible to obtain breast-milk, the best 
substitute is modified cow's milk. It is very important to begin 
with very weak mixtures in order not to upset the digestion in the 
beginning. It is very easy to kill a premature baby or to disturb 
its digestion so much that a long time is required to remedy it by 
giving too strong a mixture in the beginning. On the other hand, 
it is very easy to strengthen the mixture, if the baby is not satis- 
fied. It is never a mistake to give too weak a mixture; always a 
mistake to give a strong one. Whey mixtures are better than 
ordinary mixtures, because the protein is in a more easily digestible 
form and hence throws less work on the feeble digestive organs. 
The following mixtures are suitable ones: 

Fat 1.00% 

Milk sugar 4.00% 

Total proteins 0.25% 

Lime water 25% of the cream and milk in the mixture. 

Fat 1.00% 

Milk sugar 4.50% 

Total proteins 0.50% 

Lime water 25% of the cream and milk in the mixture. 

It is wiser to split the protein in these mixtures, making the 
whey protein and the casein the same. The mixture should be 

1 Morse: Amer. Jour, of Obstetrics, 1905, li, 589; Rott: Zeitschr. f. Kinder- 
heilk, 1913, v, 134; Hess: Amer. Jour. Diseases of Children, 1911, ii, 302; 
Zahorsky: Baby Incubators, 1905. 



THE FEEDING OF PREMATURE INFANTS 253 

gradually strengthened to cover the caloric needs, due attention 
being paid to the condition of the stools in deciding which element 
or elements to strengthen. 

Amount of Food. — Whether the food is breast-milk or modified 
milk, it is better to begin by giving one drachm (5 c. c.) at a 
feeding. If the baby is not satisfied, it is very easy to gradually 
increase the amount. It should be increased every day or every 
few feedings, if necessary. No harm can be done in giving too 
little at first; irreparable harm may be done by giving too much. 

Finally, always begin to feed premature babies with small 
amounts of a very weak food and increase the strength and amount 
at a feeding as rapidly as the individual baby's digestion will allow, 
bearing in mind that it is less dangerous to give too small amounts 
and too weak a food than to give too large amounts and too strong 
a food. If a premature baby's digestion is disturbed, it is not safe 
to give a cathartic freely and starve it. Like atrophic babies, they 
cannot bear starvation, but must be fed. 

Water. — Premature babies, because of the high temperature 
and dryness of the air by which they are surrounded, need a con- 
siderable amount of water. It is estimated that the daily ingestion 
of liquid should be one-sixth of the body weight. 

Methods of Feeding. — It is seldom advisable to put a prema- 
ture baby to the breast, because it is usually too feeble to nurse 
well and because the handling and exposure consequent on being 
put to the breast overtax the vitality too severely. When the infant 
is strong enough to take food from a nipple, it should be fed from 
the bottle. Many babies are not strong enough to do this, how- 
ever, and have to be fed in some other way. The most satisfactory 
way to feed such babies is with the Breck feeder. This consists 
essentially of a graduated glass tube, open at both ends. On the 
smaller end is a nipple about the size of the rubber of a medicine 
dropper. This is perforated and goes into the baby's mouth. On 
the other end is a large rubber finger-cot. By squeezing the 
finger-cot, milk is forced into the baby's mouth and efforts at 
sucking aided or induced. Some babies are too feeble to take food 
even in this way, and have to be fed with a medicine dropper. If a 
baby does not take its food well by any of these methods, there is 
no objection to feeding it with a tube. In fact, it often saps the 
baby's vitality less to be fed in this way than in any other. The 
passage of the tube seldom causes much strangling and vomiting, 
as the pharyngeal reflex is, in most instances, not fully developed. 
The tube should be passed through the mouth, not through the 
nose. A No. 9 or No. 10 catheter is suitable. It should be passed 



254 THE FEEDING OF PREMATURE INFANTS 

in about fifteen centimeters, the distance from the gums to the 
cardia in full-term babies being seventeen centimeters (6% inches) 
and less in the premature infant. If the baby is fed with the tube it 
is better not to give it more than eight feedings a day, fewer, if 
possible. 



SECTION IV 

DISEASES OF THE GASTROINTESTINAL 
CANAL 

CHAPTER XX 

SPASM OF THE PYLORUS 

Spasm of the pylorus is more common in infancy than is hyper- 
trophic stenosis. It is often a complication of stenosis and is not 
infrequently mistaken for it. In fact, it is probable that a very 
large majority of the cases of pyloric stenosis which have been 
reported as cured by medical treatment were not really cases of 
organic stenosis but of spasm. 

ETIOLOGY 

The etiology of spasm of the pylorus in infancy is very obscure. 
It apparently occurs most commonly in excitable and nervous 
infants, the offspring of neurotic parents. Some writers believe 
that the normal muscular hyperirritability at this age predisposes 
to pyloric spasm and that the mechanical irritation of the food or 
the chemical products of digestion thus directly or reflexly cause 
spasm when they would not in later life. Others believe that 
disturbance of the gastric digestion always precedes and causes the 
spasm. However this may be, it is certain that spasm of the 
pylorus occurs much more frequently in artificially-fed than in 
breast-fed babies. A hypersecretion of gastric juice has been found 
in some cases and hyperacidity of the gastric juice in others. The 
favorable results in many cases of treatment intended to neutralize 
hyperacidity make it seem probable that this is one of the causes, at 
least, of this condition. How large a proportion of the cases is due 
to this cause is uncertain. 

SYMPTOMATOLOGY 

In the first place, the baby is usually of the excitable, irritable 
and neurotic type. It is much more often artificially-fed than 

255 



256 DIAGNOSIS 

breast-fed. The first symptom is vomiting. It may appear imme- 
diately after birth, but usually does not develop for several weeks 
and sometimes not until the baby is several months old. In the 
milder cases this is the only symptom. It is, however, often pre- 
ceded and accompanied by evidences of gastric pain and distress. 
The vomiting is at times explosive and at others not. The amount 
of the vomitus does not ordinarily exceed the amount of food 
taken at the last meal. The vomitus shows, as a rule, little or no 
evidences of disturbance of the digestion. There is a tendency to 
constipation, but the stools show plainly that a considerable 
proportion of the food ingested passes through the pylorus into the 
intestine. The disturbance of nutrition is not extreme. 

In the more severe cases there is visible peristalsis in addition 
to the symptoms already given as characteristic of the milder 
type. These symptoms are more marked than in the mild cases, 
the stools show less fecal residue and the disturbance of nutrition is 
much greater. In the most severe cases there is also a palpable 
tumor at the pylorus. This tumor is usually small in comparison 
with that felt in hypertrophic stenosis of the pylorus. It feels 
longer and thinner. In typical cases it can be felt to appear and 
disappear under the finger as the pylorus contracts and relaxes, in 
contradistinction to the tumor in hypertrophic stenosis which does 
not change. 

Roentgenograms, taken after a bismuth meal, show very marked 
interference with the passage of the stomach contents into the 
duodenum. They seldom show, however, such complete and 
permanent obstruction at the pylorus as is commonly present in 
hypertrophic stenosis. 

DIAGNOSIS 

The differential diagnosis between spasm and hypertrophic 
stenosis of the pylorus is described in the discussion of the latter 
condition. The points of the greatest value in diagnosing spasm of 
the pylorus from indigestion with vomiting are the absence of 
evidences of indigestion in the vomitus, the explosive, projectile 
vomiting, the presence of visible peristalsis and of a palpable 
tumor, and the delay in the opening of the pylorus, shown in 
Roentgenograms taken after a bismuth meal. In habitual vomit- 
ing, the other condition with which spasm of the pylorus may be 
confused, the general condition of the baby is unaffected, the vomit- 
ing varies with the position and activity of the baby and is never 
projectile, the stools are sufficient in amount and fecal in character, 
there is no visible peristalsis and, of course, no palpable tumor. 



TREATMENT 257 

PROGNOSIS 

The prognosis is, in general, good. The symptoms persist for 
many weeks or months in the severe cases, however, even under 
the most careful treatment. Some of the most severe cases are not 
amenable to medical treatment and will die unless operated upon. 

TREATMENT 

The most important part of the treatment of pyloric spasm is 
regulation of the diet. The best food is good human milk. If this 
is vomited, it is well to remove a part of the cream and add lime 
water. The next best food is some modification of cow's milk. It 
is advisable to keep the percentage of fat low, because fat tends to 
delay the emptying of the stomach. A percentage of 0.50 is none 
too low in the beginning. It is also advisable to give as large a pro- 
portion as possible of the protein in the form of the whey proteins, 
because they are not coagulated by rennin and, therefore, easily 
pass the pylorus. Plain whey is very useful in some instances. All 
the measures which prevent the formation of large casein curds 
are applicable in this condition, in that they make the emptying 
of the stomach less difficult. Carbohydrates, which leave the stom- 
ach readily and quickly, can usually be given freely. Lactose is 
the best of the sugars in this condition. These general principles 
serve, of course, only as a basis for the preparation of the food, 
which must be varied to suit the individual baby. 

Clinically, the addition of an alkali to the food is of considerable 
assistance in many of these cases, while in others it apparently does 
no good. It presumably does good by delaying the coagulation 
of the casein by rennin and thus favoring the passage of the liquid 
milk through the pylorus. It should be added in relation to the 
milk and cream in the mixture, not in relation to the total quan- 
tity or to the whey in the mixture. It is well to add lime water 
at first to the amount of 50% of the milk and cream. If some 
other alkali is used, a corresponding amount should be given. 
Cowie * believes that the action of the alkali is dependent on the 
degree of the acidity of the gastric contents and the effect of the 
change of the reaction of the gastric contents on the pyloric reflex. 
If his explanation is correct, it is possible to exaggerate the condi- 
tion by giving alkalis, and in any case the alkalis must be added 
very carefully, preferably on the basis of the findings obtained by 
the analysis of the gastric acidity. 

1 American Journal of Diseases of Children, 1913, v, 225. 



258 TREATMENT 

There is much difference of opinion as to whether the food should 
be given at short or long intervals and as to the quantity which 
should be given at a feeding. The most rational way of regulating 
the interval between feedings is to determine how long it takes the 
stomach to empty itself in the individual case and to make the in- 
tervals somewhat longer than this. In general, it is probably bet- 
ter to give small amounts at a feeding, although there are many 
exceptions to this rule. 

Daily lavage with plain water or a weak solution of bicarbonate 
of soda is of assistance in most cases, although some authors think 
that it tends to keep up the spasm. Warm applications to the 
epigastrium for one-half an hour before and one-half an hour after 
feeding are sometimes of assistance. Flaxseed meal poultices are 
the most efficacious. Minute doses of some preparation of opium — 
& Q-, tV °f a minim of the tincture — given a short time before 
feedings sometimes seem to diminish the spasm. Atropine and 
cocaine have also been used for the same purpose. It is also im- 
portant to keep these babies very quiet, especially immediately 
after feeding. 

Rosenhaupt l claims good results in this condition from rectal 
irrigations of salt solution, basing his treatment on Engel's state- 
ment that the cause of the trouble is gastrosuccorrhcea and on 
Benczur's experiments which show that in animals rectal injec- 
tions of salt solution diminish the secretion of gastric juice. He 
obtained favorable results in all but one case, but does not state 
how many patients he treated. Rosenstern claims good results 
in four cases from the rectal instillation of from 250 c. c. to 400 c. c. 
of Ringer's solution daily. This method of treatment is, however, 
so new that it must be regarded as still sub judice. 

Surgical intervention for the relief of pyloric spasm is seldom 
necessary. Experience has shown, however, that babies sometimes 
die of this condition under medical treatment. When, therefore, 
a baby is steadily going down hill under medical treatment, sur- 
gical intervention is indicated. An operation will relieve the symp- 
toms and save the baby's life, just as it does in hypertrophic 
stenosis of the pylorus. The spasm will cease in time. When this 
happens and there is no longer any obstruction to the passage of 
the food through the pylorus, the food will then pass through the 
pylorus, the opening from the stomach into the bowel will close 
and the normal conditions be reestablished. 

1 Deutsche med. Woch., 1909, xxxv, 1789. 



CHAPTER XXI 
HYPERTROPHIC STENOSIS OF THE PYLORUS 

The pathological condition in this disease is an overgrowth of 
the circular muscular fibers of the pylorus. The longitudinal fibres 
are little, if at all, involved. The normal longitudinal folds of the 
mucous membrane lining the pylorus are hypertrophied. There is 
at times a slight increase in the connective tissue of the submucosa, 
The opening of the pylorus, which normally admits a No. 21 sound. 
French scale, is narrowed by the thickened muscle and the folds 
of mucous membrane until, in well-marked cases, it will not allow 
the passage of even a fine probe. In extreme cases it is impossible 
to force water through the pyloric opening. The tumor is usually 
about the size and shape of a dressed olive. 

There is more or less hypertrophy of the muscles of the stomach 
wall in all cases. There is also almost always some enlargement 
of the stomach. This enlargement of the stomach may be consid- 
erable in advanced cases. The oesophagus is also sometimes some- 
what dilated. The intestines are collapsed and empty. There are 
no evidences of inflammation and in most instances there is no 
catarrhal condition of the gastric mucosa. There is general wast- 
ing of all the organs and tissues as the result of starvation. 

The muscular hypertrophy is sufficient after a few weeks, in the 
great majority of instances, to practically occlude the pyloric ori- 
fice and to almost or entirely prevent the passage of the gastric 
contents into the duodenum. It is probable that in other instances 
the hypertrophy is less marked and the narrowing of the lumen 
consequently less extreme. It is presumable that this hyper- 
trophy is at the bottom of some of the cases of pyloric obstruction 
which develop in late childhood and adult life. It is possible that 
when the overgrowth is slight it may be neutralized by the growth 
of the parts with age. The facts that the conditions found at au- 
topsy in one instance some months after gastroenterostomy for a 
complete obstruction were the same as at the time of the oper- 
ation 1 and that Roentgenograms show that the food continues to 
pass through the new stoma for years after the operation indicate, 

1 Morse, Murphy and Wolbach: Boston Medical and Surgical Journal, 
1908, clviii, 480. 

259 



260 SYMPTOMATOLOGY 

however, that there is no diminution in the hypertrophy in those 
instances in which it is marked. 



ETIOLOGY 

The etiology of this condition is obscure and has given rise to 
much discussion. The weight of the evidence, however, is in favor 
of the view that it is a congenital abnormality rather than the 
result of muscular spasm, acting either before or after birth. 
There is no doubt, on the other hand, that in many instances in 
which the stenosis is not complete, the symptoms are exaggerated 
by spasm. 

Hypertrophic stenosis of the pylorus occurs more frequently in 
boys than in girls. It is just as common in breast-fed babies as in 
the artificially-fed. 

SYMPTOMATOLOGY 

The first symptom is vomiting. It may begin in the first few 
days of life, but ordinarily does not appear before the beginning 
of the second week. It seldom develops after the first month. 
There is nothing characteristic about the vomiting in the begin- 
ning. It soon becomes forcible and explosive. The gastric con- 
tents may be shot out of the mouth to a distance of several feet. 
The vomiting usually occurs soon after the taking of food, but may 
occur at any time, sometimes not until just before the next feeding. 
Two, or even more feedings, are sometimes retained and expelled 
together. The whole of the stomach contents is usually vomited 
at one time. The vomiting is in most instances not accompanied 
by pain. The vomitus consists in the beginning simply of the food 
taken, which is more or less digested according to the interval 
which has elapsed between its ingestion and the vomiting. Later 
on it often contains mucus, but never, except in the rarest instances, 
bile. There is nothing characteristic about the reaction of the gas- 
tric contents. The baby is anxious to eat again immediately after 
it has vomited, unless it is temporarily exhausted by the process. 
In spite of the frequent vomiting, the tongue is clean and the 
breath sweet. 

Constipation quickly develops, because so little of the food 
passes through the pylorus into the intestine that there is but lit- 
tle residue to be passed out of the bowels. The stools are small 
and, being composed of the same materials as the meconium, re- 
semble it in appearance. 

Loss of weight is a constant symptom. It is progressive and be- 



PHYSICAL EXAMINATION 261 

comes more rapid as time goes on. It is due, of course, to the 
lack of food and liquid as the result of the vomiting. The skin 
becomes dry, the face pinched and the baby soon shows all the 
evidences of starvation. 



PHYSICAL EXAMINATION 

The abdomen at first shows nothing abnormal on inspection. 
After a time, however, the epigastrium appears full when food is 
taken, and the rest of the abdomen sunken. When there is dilata- 
tion of the stomach, it may be recognized by inspection and palpa- 
tion. Great care must be excercised in diagnosing dilatation of the 
stomach, however, because of the great variation in the normal 
position of this organ. Waves of peristalsis, running across the 
stomach from left to right, appear soon after the vomiting becomes 
marked. They occur only, of course, when the stomach has some- 
thing in it. If they do not appear soon after food is taken, they can 
often be elicited by stroking the epigastrium, flicking it with a 
towel wet in cold water, or by the application of a piece of ice. 
They are usually about the size of half an egg and run very slowly 
across the epigastrium. Two, or even three, waves are sometimes 
visible at the same time. 

A tumor can be felt in most instances. It is usually situated 
about midway between the tip of the ensiform and the navel and 
between one-half an inch and one inch to the right of the median 
line. This position is, however, not a constant one. The tumor is 
not infrequently under the edge of the liver. It ordinarily feels 
much like a dressed olive, both in size and shape. It does not vary 
in size. It may be mistaken for a large gland. If peristaltic waves 
are present, the tumor will often be found where they disappear. 
The tumor may be felt at any time. It is usually easier to find it 
when the stomach is empty than when it is full, but the opposite is 
sometimes the case. If there is any reason to suspect the presence 
of a pyloric tumor, the abdomen should always be examined with 
the stomach both full and empty. This is easily accomplished by 
having the baby fed or with the aid of a stomach-tube. The tu- 
mor is most easily felt during the relaxation after vomiting. An 
anaesthetic may be used to produce relaxation, if necessary. 

Under normal conditions, Roentgenograms of the stomach, 
taken immediately after a meal containing bismuth, show food 
passing through the pylorus into the duodenum. Roentgenograms 
taken at intervals afterwards show that the stomach is empty 
in most instances in from two to four hours. When there 



262 DIAGNOSIS 

is stenosis of the pylorus, Roentgenograms taken at once show 
notliing passing through the pylorus. Those taken afterwards 
show that little or nothing passes through the pylorus and show 
bismuth in the stomach for many hours, unless it has been vomited. 
It is impossible to pass a duodenal catheter, if there is stenosis. 
In many instances in which the muscular hypertrophy is not 
extreme, and presumably in most cases in the beginning, the nar- 
rowing of the pyloric canal which is caused by the mechanical ob- 
struction of the tumor is increased by spasm of the muscle. It is 
the spasm of the muscle wluch accounts for the variation in the 
severity, or even intermittency, of the symptoms in many cases 
and for the sudden onset of severe symptoms in others. When 
a part of the obstruction is due to spasm, everything may be vom- 
ited for a time and then, when the spasm ceases, a considerable part 
of the food will be retained. The character of the stools will vary 
at the same time, resembling meconium when the spasm is marked 
and being fecal when it diminishes. 

DIAGNOSIS 

The diagnosis of a well-marked case of hypertrophic stenosis of 
the pylorus is very easy. The combination of vomiting, beginning 
within a few days or weeks after birth, increasing steadily in se- 
verity, becoming projectile in character and having no relation 
to the character of the food, marked constipation with meconium- 
like stools, visible gastric peristalsis and a palpable tumor, not 
varying in size, in the region of the pylorus, is pathognomonic. Al- 
though the tumor at the pylorus can almost always be found if 
carefully sought for under the proper conditions, a positive diagno- 
sis of this condition is justifiable, if the other symptoms and signs 
are present, even if the tumor cannot be made out. The diagnosis 
should always be confirmed, however, if possible, by Roentgen- 
ograms taken after a bismuth meal and the duodenal catheter. 

The diagnosis between hypertrophic stenosis of the pylorus and 
spasm of the pylorus is, however, at times a very difficult one. The 
onset of the symptoms is the same in both, the vomiting is explo- 
sive in both and there is visible peristalsis in both. Constipation 
and loss of weight are common to both. There is sometimes a pal- 
pable tumor in spasm; the tumor is sometimes not palpable in hy- 
pertrophic stenosis. In spite of the similarity of the symptoms of 
the two diseases, there should be little difficulty in distinguishing 
the marked cases of hypertrophic stenosis from those of spasm, be- 
cause the constipation is never so marked or persistent in spasm as 
in stenosis and because the tumor in spasm is small and cord-like, 



DIAGNOSIS 263 

not large and hard as in hypertrophic.stenosis. Variation in the 
size of the tumor during examination is practically positive proof 
that the condition is one of spasm, not of hypertrophy. The dif- 
ficulty in diagnosis comes between the severe cases of spasm and 
the mild cases of hypertrophic stenosis, because the difference in 
the symptomatology of the two diseases is entirely in the degree, 
not in the kind, of the symptoms. 

It is impossible in many instances to make at first a positive 
diagnosis between these two conditions. If the baby is breast-fed, 
the chances are much in favor of hypertrophic stenosis, because 
spasm is very unusual in the breast-fed while hypertrophic steno- 
sis is equally common in the breast-fed and in the artificially-fed. 
If the baby is artificially-fed, the chances are even, although if the 
feeding has been very irrational, spasm is a little the more probable. 
The absence of a palpable tumor is strong evidence against hyper- 
trophic stenosis, but does not positively exclude it, because a good- 
sized tumor has sometimes been found at operation when none was 
felt before. It is never safe to conclude that there is no tumor, 
however, unless the abdomen has been examined with the stomach 
both full and empty, and with the abdominal walls relaxed, if nec- 
essary under an anaesthetic. If no tumor is felt under these con- 
ditions, an almost positive diagnosis of spasm is justified. Exam- 
ination of the gastric contents is of little or no assistance, because 
there are very few reliable data as to the chemistry of the gastric 
contents in these conditions and what few data there are are con- 
tradictory. An excessive hyperacidity perhaps counts a little, 
however, in favor of spasm. Dilatation of the stomach seldom de- 
velops in simple spasm of the pylorus and, if it does, is always 
slight. It develops in a certain proportion of the cases of hyper- 
trophic stenosis, but is seldom extreme. The presence of dilata- 
tion is, therefore, in favor of hypertrophic stenosis and against 
spasm. Its absence does not count at all in favor of spasm. Dilata- 
tion of the stomach, unless extreme, is very difficult of demonstra- 
tion in infancy. Too much importance must not be attached, 
therefore, to what are apparently slight degrees of dilatation. 
Rapid improvement under medical treatment and regulation of the 
diet is strong evidence in favor of spasm, but does not positively 
exclude a mild degree of hypertrophic stenosis complicated by 
spasm. The most important points in favor of spasm in doubtful 
cases are, therefore, the absence of a palpable tumor or, if a tumor 
is present, its cord-like feel, the presence of intermittent contrac- 
tion and relaxation of the tumor, and rapid improvement under 
medical treatment and regulation of the diet. 



264 DIAGNOSIS 

Roentgenograms are of less value in the diagnosis between severe 
cases of spasm of the pylorus and mild cases of stenosis than be- 
tween stenosis and other conditions, because there is obstruction 
at the pylorus and therefore delay both in the opening of the py- 
lorus and in the emptying of the stomach in both cases. 

When hypertrophic stenosis of the pylorus of slight or mod- 
erate degree is complicated by spasm of the pylorus, the varia- 
tion in the severity of the symptoms and the temporary response 
to medical treatment and regulation of the diet are often most 
confusing. When there is hypertrophy there is, however, almost 
always, in spite of the variation in the symptoms, a progres- 
sive increase in their severity. The presence of a tumor which 
does not change in size or shape is conclusive proof that there is 
an organic stenosis, no matter how much the other symptoms 
may vary. 

The diagnosis between hypertrophic stenosis of the pylorus and 
indigestion with vomiting is a comparatively simple one. Indiges- 
tion seldom occurs in the breast-fed, but develops, as a rule, after a 
longer or shorter period of bad artificial feeding. Vomiting is the 
most prominent symptom, occurs without any definite relation to 
the time of taking food, and is never explosive. The amount of the 
vomitus rarely exceeds that of the food taken at the last feeding 
and the vomitus usually shows evidence of disturbance of the 
gastric digestion. The stools often present the evidences of an 
associated intestinal indigestion, but constipation, as the result 
of the reduction in the amount of food retained, is not uncommon. 
The stools are, however, never of the starvation type, but show by 
their characteristics that food is passing from the stomach into the 
bowel. There is never any visible peristalsis and, of course, no 
tumor to be felt at the pylorus. Roentgenograms taken after a 
bismuth meal will settle the diagnosis at once in doubtful cases, 
because the food begins to leave the stomach immediately in indi- 
gestion, while nothing passes the pylorus for a long time when there 
is obstruction from a pyloric tumor. 

Another condition which sometimes suggests hypertrophic 
stenosis of the pylorus is habitual vomiting. In this condition the 
baby without any other symptoms of indigestion vomits habit- 
ually. In spite of the vomiting, it nevertheless has stools normal in 
size and appearance and gains steadily in weight. These points are 
of themselves sufficient to rule out stenosis of the pylorus. Fur- 
ther points in which the symptomatology of this condition varies 
from that of stenosis are that the vomiting rarely occurs when the 
baby is quiet and that it varies with the amount of exertion and the 



PROGNOSIS AND TREATMENT 265 

position of the baby. The vomiting is never explosive and there is 
no visible peristalsis or palpable tumor. The vomiting in this con- 
dition is sometimes due to an excessive amount of food, but more 
often, probably, to the lack of tone or imperfect closure of the car- 
diac orifice. 

PROGNOSIS AND TREATMENT 

The prognosis of hypertrophic stenosis of the pylorus, when the 
obstruction is marked and due wholly or chiefly to the muscular 
hypertrophy, is hopeless under medical treatment. Death will 
surely ensue in a few weeks as the result of starvation. These 
cases can be saved, however, by an operation, provided the opera- 
tion is done at a time when the baby is able to stand the shock of 
the operation, which is a severe one. They should be operated 
upon as soon as the diagnosis is made. Every day of delay mate- 
rially diminishes their chances of recovery. The best operation is 
the splitting of the pylorus, the so-called Rammstedt operation. 
This is far preferable to posterior gastroenterostomy or the modi- 
fied pyloroplasty recommended by Dr. Keef e. 1 Both of these opera- 
tions require especial skill and should be performed only by sur- 
geons who are in the habit of operating on infants or have had much 
experience in operating on small animals. The Rammstedt opera- 
tion can be easily performed, however, by any surgeon. It requires, 
moreover, much less time and is accompanied by much less shock. 

The medical treatment of these cases both before and after 
operation is of considerable importance. They should be given 
salt solution by enema or seepage, and if necessary subcutaneously, 
before the operation. The stomach should be washed out just 
before the operation. Salt solution should be given in the same 
ways after the operation. Feeding should be begun as soon as the 
baby has thoroughly recovered from the effects of the anaesthetic. 
The best food is human milk, diluted at first with three parts of 
water, the strength being quickly increased. If this is not available, 
the next best thing is whey. This should be gradually strengthened 
by the addition of gravity cream to give 0.25% of fat, 0.50% of fat 
and 1.00% of fat. The regulation of the food from this time on is 
usually comparatively simple and along the general lines of infant 
feeding. It is advisable to begin to feed with one drachm (5 c. c.) 
every hour, increasing the amount and lengthening the interval 
between feedings as rapidly as possible. There is very little danger 
of overloading the stomach, because there is no obstacle to the 
passage of the food from the stomach into the intestine. The 

1 Boston Med. and Surg. Journal, 1913, clxix, 318. 



266 PROGNOSIS 

difficulty lies in the intestine, which has not been in the habit of 
receiving large amounts of food. If the intestine is contracted, as it 
is in most cases which are operated on late in the disease, it is 
unable to take care of much food. If the operation is performed 
early, before contraction of the intestine has taken place, large 
amounts of food can generally be given. 

The future development of babies in whom a posterior gastroen- 
terostomy has been successfully done for hypertrophic stenosis of 
the pylorus is normal and their processes of digestion and absorp- 
tion are not impaired. 1 The tumor does not diminish in size, how- 
ever, the lumen of the pylorus is not restored and the food con- 
tinues to pass through the gastroenterostomy opening. 2 The fu- 
ture development of babies on whom the Rammstedt operation 
has been performed is also normal. The food continues to pass 
freely through the pylorus and in one instance it was found five 
months after the operation that the pyloric tumor had disap- 
peared. 3 

When the condition is one of partial stenosis complicated by 
spasm, the treatment is primarily that of spasm of the pylorus. 
The methods to be employed are described in the treatment of this 
condition. It is wiser, however, to operate in this condition also, 
unless the symptoms are quickly and almost entirely relieved. 
Unless this is done, the nutrition of the infant is certain to be 
materially impaired and its development retarded. There is but 
little reason to anticipate, moreover, that the organic obstruction 
will diminish in the future. It is also not improbable that a certain 
proportion of the cases of benign obstruction at the pylorus which 
develop in later childhood and early adult life are the result of mild 
degrees of infantile hypertrophic stenosis. 

^cudder: Surgery, Gynecology and Obstetrics, 1910, xi, 275; Talbot: 
Boston Medical and Surgical Journal, 1910, clxi, 782, and 1910, clxii, 490. 

2 Scudder* Surgery, Gynecology and Obstetrics, 1910, xi, 275; Morse, 
Murphy and Wolbach: Boston Medical and Surgical Journal, 1908, clviii, 
480; Koplik: American Journal Medical Sciences, 1908, cxxxvi, i. 

3 Rachford: Archives of Pediatrics, 1917, xxxiv, 803. 



CHAPTER XXII 
NERVOUS DISTURBANCES OF THE DIGESTIVE TRACT 

Symptoms pointing to disturbance in the digestive tract develop 
not very infrequently as the result of causes or conditions acting 
directly on the nervous system. The symptoms referable to the 
digestive tract are due to disturbance of the functions of this tract 
as the result of abnormal influences transmitted to it from the 
unduly irritable or exhausted nervous centers. The most char- 
acteristic symptoms are those due to the disturbance of the 
mechanical functions of the stomach and intestines. When the 
symptoms are due to disturbance of the secretory functions of the 
digestive tract, they are indistinguishable from those due to dis- 
turbance of these functions from other causes. In fact, the condi- 
tion is then an indigestion. Only those symptoms due to dis- 
turbance of the mechanical functions will, therefore, be described. 

The most common of the causes acting through the nervous 
system are extremes of temperature, whether of heat or cold, more 
commonly of heat. Diarrhea is a more common result than 
vomiting. The vomitus consists simply of the contents of the 
stomach and shows no evidences of indigestion. The diarrhea is 
due to increased intestinal peristalsis. The intestinal contents are, 
in consequence, hurried through the bowels. The stools are, 
therefore, normal in every way, except that they are increased in 
number and diminished in consistency. Excitement and fear may 
have the same effect as extremes of temperature. The body 
temperature is not altered in these cases. There may, however, be 
a certain amount of abdominal discomfort and general constitu- 
tional depression. 

It is conceivable that improper and indigestible food, acting sim- 
ply as a foreign body, may, through irritation of the stomach and 
intestines, reflexly cause vomiting and diarrhea without producing 
any disturbance of the digestive functions. If this occurs, it is, 
however, very uncommon. In such instances the vomitus and 
stools will contain the food which is the cause of the symptoms. 

The primary cause of many of the more chronic disturbances of 
digestion is some error in the infant's care and routine, which 
results in over-excitement and exhaustion of the nervous system, 

267 



268 NERVOUS DISTURBANCES OF DIGESTIVE TRACT 

rather than improper food. Constant attention, noisy surround- 
ings, lack of rest and sleep will often be found to be at the bottom 
of intractable cases of indigestion in infancy. No change in the 
diet will benefit them in any way, but they will begin to improve 
at once when the undue strain on the nervous system is removed. 

TREATMENT 

The first element in the treatment of these disturbances of the 
digestive tract due to causes acting through the nervous system is 
the removal of the cause. Recovery is usually prompt, when this 
is removed. It is also wise to omit one or two feedings and then to 
give the usual food weakened for one or two days. If the baby is 
on the breast, the duration of the nursings should be shortened and 
boiled water given before or during the nursing in order to dilute 
the milk. If the baby is taking an artificial food, it should be 
diluted with water. If the baby is on a mixed diet, the less easily 
digestible articles should be omitted. 

If the cause of the trouble is indigestible food, it is best to give a 
laxative, such as milk of magnesia or phosphate of soda, to hurry it 
out of the bowels before it can set up a disturbance of the digestion. 
A laxative is not necessary, except when improper food is the cause. 

If improper food is not the cause of the trouble and the baby is 
having a large number of loose stools, normal in other ways, it is 
allowable to diminish the excessive peristalsis by giving paregoric in 
doses of from five to twenty drops every two or four hours, accord- 
ing to the age of the child and the severity of the symptoms. 



CHAPTER XXIII 
DISTURBANCES OF DIGESTION 

Disturbance of the digestion may be caused by an excess of an 
otherwise suitable food, by a too rich but otherwise well-balanced 
food and by foods containing an excessive amount of one or of 
several of the food elements. It may also be caused indirectly by 
other diseases or by any extraneous causes which weaken the gen- 
eral resistance or diminish the digestive powers. The disturb- 
ance may be either acute or chronic. The pathological changes in 
the gastroenteric tract are insignificant. In many instances there 
are no macroscopic changes beyond thinning of the intestinal wall. 
In others there is reddening of the surface and an excessive secre- 
tion of mucus, while in a few there is a desquamation of the super- 
ficial epithelium. The microscopic changes are slight and unim- 
portant. In the more chronic cases there is a general wasting of 
all the tissues of the body and in both the acute and chronic cases 
there may be degenerative changes, frequently fatty, in the paren- 
chymatous organs. The important changes are in the metabolic 
processes of the body. These are not recognizable pathologically. 
They are at present imperfectly understood. They vary accord- 
ing to which of the food elements is the cause of the indigestion. 

Disturbances of the digestion are much less common in the 
breast-fed than in the artificially-fed. The symptoms are also, as 
a rule, less severe. All disturbances of the digestion, whatever 
their cause, have many symptoms in common. The other symp- 
toms vary in accordance with the food element which is at the 
bottom of the disturbance. Disturbances of the digestion due to 
an excess of fat are likely to be more serious and more lasting than 
those due to the other food elements. Those due to an excess of 
sugar are more often acute and more often rapidly fatal. Those 
due to an excess of protein are apparently less frequent and less 
serious than those due to the other food elements. It must be re- 
membered in this connection, however, that this apparent infre- 
quency may be due to failure to recognize the symptoms and that 
the protein may really be at fault when the blame is attached to one 
of the other elements. 

Simple disturbances of the digestion may be associated with 

269 



270 DISTURBANCES OF DIGESTION 

fermentation of the improperly digested intestinal contents as the 
result of bacterial activity. It is probable, in fact, that there is 
more or less fermentation in almost every case. When these fer- 
mentative processes are marked they often predominate the pic- 
ture and the condition is then spoken of as indigestion with fer- 
mentation. The borderline between indigestion with bacterial 
fermentation and without it is, however, a very indefinite one. In 
many instances it is, therefore, impossible to determine in which 
class a given case belongs. 

The following classification will be adopted in discussing the 
disturbances of digestion: 

Indigestion. 

1. Indigestion from an excess of food. 

2. Indigestion from an excess of an individual food element. 

a. Fat 

b. Carbohydrates 

c. Protein 

d. Salts. 

3. Indigestion with fermentation. 

INDIGESTION FROM AN EXCESS OF FOOD 

Breast-Milk. — Indigestion from an excessive amount of breast- 
milk is comparatively uncommon, because of the fact that Nature 
tends to accommodate the supply of milk to the demand and be- 
cause, if an excessive amount is taken, the baby is very likely to 
regurgitate it before it has had time to cause any disturbance of the 
digestion. Indigestion from an excessively rich breast-milk is also 
somewhat uncommon. 

The main symptoms of indigestion from an excessive amount of 
breast-milk or an excessively strong breast-milk are vomiting, an 
increased number of stools, failure to gain properly in weight, flat- 
ulence and colic. The babies are, as a rule, somewhat fussy and 
do not sleep well. The symptoms are seldom very marked. When 
the difficulty is in the strength of the milk, they are very likely to 
lose their appetites. There is nothing characteristic about the 
vomitus. The stools usually contain fat curds and more or less 
mucus. 

The condition is seldom a serious one. It is usually easily cor- 
rected. 

When there is too much milk, the duration of the nursing must 
be shortened. How much it should be shortened can usually be 
determined by observation of the baby's symptoms. More accu- 



DISTURBANCES OF DIGESTION 271 

rate results can be obtained, however, by weighing the baby at 
intervals during the nursing and stopping the nursing when the 
desired amount has been obtained. The failure to empty the 
breasts will usually quickly bring about a diminution in the sup- 
ply of milk. The mother should limit her ingestion of liquids 
until this happens. 

When the breast-milk is excessively rich, the intervals between 
the nursings should be lengthened, as this procedure tends to di- 
minish the amount of solids in the milk. The mother should eat 
more simple food and should take more exercise. Water should 
be given at the time of the nursing, to dilute the milk, until the 
strength of the milk has become normal. The amount of water 
to be given depends on the age of the baby and the strength of the 
milk. It may be given with a spoon or in a bottle before or during 
the nursing, or through a dropper introduced into the mouth be- 
side the nipple during the nursing. It is almost never necessary to 
wean a baby because of an excessively strong breast-milk. 

Artificial Food. — Indigestion from an artificial food, suitable 
in every way except that too much of it is given or that it is too 
strong in all its percentages, is more common than that from an 
excessive amount or strength of breast-milk, but infinitely less 
common than that from an artificial food containing an excessive 
amount of one or two of the food elements. 

The symptoms of indigestion from an excessive amount of a 
suitable food or of too strong a food are loss of appetite, vomiting, 
an excessive number of stools, flatulence and colic, and failure to 
gain in, or loss of, weight. The babies are, as a rule, fussy and ir- 
ritable and sleep poorly. The vomitus is not characteristic, but 
may show the evidences of disturbance of the digestion of any or 
all of the food elements. The stools are also not characteristic, 
and may also show evidences of the disturbance of the digestion of 
any or all of the food elements. Evidences of disturbance of the 
digestion of fat are, perhaps, the most common. If there is a con- 
siderable amount of vomiting, the stools may be constipated, be- 
cause of the lack of sufficient food remnants to form the normal 
amount of feces. 

The prognosis of indigestion due to too much of a good food or 
to an excessively rich, but otherwise suitable, food is usually good. 
The condition usually yields readily to proper treatment. 

The treatment consists primarily in cutting down the amount of 
food or in weakening the food. It is advisable in most instances to 
weaken the food considerably more than enough to bring it to the 
strength which would be suitable for the average normal baby of 



272 FAT INDIGESTION 

the given age. This is necessary, because the digestive processes 
have usually been so weakened by the excessive demands upon 
them that they are unequal to meet even the usual demands. 
After the digestive powers have recovered themselves, the food 
can gradually be strengthened. It is usually possible to straighten 
out these cases without a wet-nurse. 

When the disturbance is an acute one from a temporary indis- 
cretion the intestines should be emptied with castor oil or milk of 
magnesia and all food stopped for from twelve to twenty-four 
hours. When the disturbance is a chronic one, it is often advisable 
to begin treatment with a cathartic. It is not advisable to stop 
food, even for a time. 

INDIGESTION FROM AN EXCESS OF FAT 

Breast-Milk. — Indigestion from an excessive amount of fat 
in breast-milk is comparatively uncommon. The percentage of fat 
is seldom very high and, even if it is, babies are usually able to 
accommodate themselves to it. 

The main symptoms of an excessive amount of fat in breast-milk 
are loss of appetite, vomiting and abnormal stools, with more or 
less flatulence and colic. Failure to gain in weight or a moderate 
loss of weight become manifest after a time. The symptoms are, 
however, seldom serious. There is usually nothing especially ab- 
normal about the vomitus. It may, however, in the more severe 
cases, have the odor of butyric and other fatty acids. The stools 
contain many small, soft curds, and sometimes have an oily ap- 
pearance. They are more acid than normal and may cause irrita- 
tion of the buttocks. Soap stools are most unusual as the result 
of an excess of fat in breast-milk. 

The disturbance caused by an excessive amount of fat in breast- 
milk is seldom a severe one, is not usually of long duration and is 
ordinarily easily corrected. 

The amount of fat in the milk can sometimes be reduced by cut- 
ting down the fat in the mother's diet, provided she has been eat- 
ing an excessive amount of it. In most instances, however, it will 
be found that she has been eating too much in general rather than 
too much fat. Cutting down her food as a whole, increasing the 
amount of the exercise which she takes and getting her out of doors 
more will usually promptly bring the amount of fat down to within 
normal limits. Shortening the duration of the nursings in order 
that the baby shall not entirely empty the breast is of some advan- 
tage, because the fore-milk contains less fat than the last milk or 



FAT INDIGESTION 273 

"strippings." If the duration of the nursings is shortened, the in- 
tervals between the nursings must also be diminished in order that 
the baby may get enough food. Water may be given at the time 
of the nursing in order to diminish the percentage of fat by dilut- 
ing the milk. This procedure has the disadvantage, however, of 
diminishing the percentage of the other food elements as well as 
that of the fat. 

Artificial Food. — Indigestion is more often due to an excess of fat 
in artificial food than to an excess of any other single element. The 
results of a disturbance of the digestion from an excess of fat are, 
moreover, more far-reaching, more lasting and more difficult to 
correct than those due to any other element. 

The symptoms are, in general, loss of appetite, flatulence and 
colic, vomiting, abnormal stools and failure to gain in weight or, 
more often, progressive loss of weight. The temperature is often 
elevated in acute disturbances of the digestion caused by fat, but 
is likely to be somewhat subnormal in the chronic disturbances. 

The vomitus is acid in reaction and has a strongly acid odor. 
This odor is due to the presence of butyric and other fatty acids. 
It sometimes has a creamy appearance. 

The most common abnormality in the stools is the presence of 
many small, soft curds. These are often accompanied by mucus. 
In other instances the stools have a gray, shiny appearance. When 
there is an excess of neutral fat, the stools may be of a creamy con- 
sistency and are often about the color of cream. In other instances 
they look like curdled milk. More often, especially in the chronic 
cases, the stools are gray, or grayish-yellow, large, hard and dry. 
They may sometimes be so dry as to be crumbly. The fat in these 
stools is in combination with calcium and magnesium in the form 
of soap, that is, these are the typical "soap stools." In other 
instances, the stools are watery, strongly acid, and cause marked 
irritation of the buttocks. When this happens, the fat is in com- 
bination with the alkaline salts, especially sodium. 

When there is an acute disturbance of the digestion as the re- 
sult of an excess of fat in the food, there is not infrequently a high 
fever. When there is diarrhea, as there often is in the acute dis- 
turbances, there is not only an excessive loss of fat in the stools, 
but also a very considerable loss of alkaline salts, especially sodium. 
A relative acidosis results, with an excess of ammonia in the urine. 
The symptoms of acid intoxication may then develop. The most 
characteristic of these are rapid and deep respiration, stupor or 
restlessness, and cherry-red lips. 

When the disturbance of the digestion is a chronic one, there is 



274 FAT INDIGESTION 

a continuous loss of magnesium and calcuim in the stools and a 
consequent disturbance of the metabolism. This shows itself not 
only in a chronic disturbance of the nutrition but also by the de- 
velopment of the manifestations of rickets and of the symptoms 
of the spasmophilic diathesis. The manifestations of the disturb- 
ances of the nutrition as the result of the disturbance of the me- 
tabolism of the salts may become most marked, so that the babies 
come to present the characteristic picture of "marasmus" or "in- 
fantile atrophy." 

The prognosis in disturbances of the digestion due to an excess of 
fat in an artificial food depends on whether the condition is acute or 
chronic. If the condition is an acute one, it varies with the se- 
verity of the symptoms, but is, in general, good. If the condition 
is a chronic one, the prognosis depends on the severity of the symp- 
toms, the duration of the trouble and the degree of the disturbance 
of the nutrition. It is very grave in the more marked cases and re- 
covery is always slow, even in the mild cases. It always takes a 
long time to reestablish a normal tolerance for fat. Relapses are 
frequent and of long duration. The least excess of fat in the food is 
almost certain to bring one on. 

The treatment of disturbances of the digestion caused by an ex- 
cessive amount of fat in an artificial food consists in diminishing 
the percentage of fat in the food. How much the percentage of 
fat is to be cut down depends on the severity and duration of the 
symptoms in the individual instance. 

It is usually advisable to cut out the fat entirely in acute cases. 
In them, however, it can usually be cautiously added again in a 
few days. How rapidly it can be added can only be determined by 
observation of the symptoms and examination of the stools. 

It is also advisable to cut out all of the fat in beginning the 
treatment of the severe, chronic cases of fat indigestion. In the 
less serious cases it is always wise to at once reduce the percentage 
of fat materially. Time is saved, recovery is hastened and toler- 
ance established much more quickly, when the percentage of fat 
is immediately cut down below the limit of tolerance than when 
this point is reached by several insufficient reductions. It is never 
a mistake to reduce the percentage of fat more than is necessary. 
Time is always lost, if the reduction is insufficient. It is usually ad- 
visable to reduce the fat to at least 2% in the mild cases, to 1% in 
the more severe ones, and to cut it out entirely in the most serious. 
If the stools still show an excessive amount of fat after the initial re- 
duction has been made, the percentage of fat must be reduced still 
farther. If they do not show any evidences of fat indigestion, the 



FAT INDIGESTION 275 

percentage of fat should be cautiously increased. Not more than 
0.25% should be added at a time. Several days should intervene 
between the changes. The stools should be examined after each 
change is made to determine if this amount of fat is well borne be- 
fore the next change is made. It must never be forgotten that 
when the tolerance for fat has once been weakened, it is very- 
difficult to reestablish it and very easy to break it down again. 

It must be remembered, on the other hand, that the continuous 
use of a food low in fat tends to weaken the power of digesting fat 
and, therefore, to lower the tolerance for fat. It must also be re- 
membered that the caloric value of fat is very high and that, if the 
percentage of fat is very low, the caloric value of the food may be 
insufficient to meet the infant's caloric requirements. When the 
percentage of fat is much diminished, the percentages of the car- 
bohydrates and protein must be increased in order to cover the ca- 
loric needs. This is sometimes very difficult to do without setting 
up a disturbance of the digestion through an excess of one of the 
other food elements, since the caloric value of fat is more than twice 
that of sugar, starch and protein. 

Babies with an almost complete intolerance for the fat of cow's 
milk can often take the fat of human milk without difficulty. 
When, as is sometimes the case, it is impossible to feed babies hav- 
ing an intolerance for fat satisfactorily on artificial foods low in fat 
on account of the disturbance of the digestion caused by the other 
food elements, when the percentages of these elements are made 
high enough to cover the caloric needs, they should be given human 
milk. In some cases unfortunately, they are unable to tolerate the 
fat of human milk. In such instances skimmed human milk is the 
only resource. 

INDIGESTION FROM AN EXCESS OF CARBOHYDRATES 

Breast-Milk. — Indigestion from an excess of sugar in breast- 
milk is decidedly uncommon. The percentage of sugar is very 
seldom over seven and, if it is 1 or 2% higher, it almost never 
causes any disturbance. 

The main symptoms of an excessive amount of sugar in breast- 
milk are flatulence and colic, vomiting and abnormal stools. The 
disturbance is seldom sufficient to cause any loss of weight. There 
is nothing especially characteristic about the vomitus. It may, 
however, sometimes have the odor of lactic or acetic acid. The 
stools are usually not especially characteristic. They are, however, 
sometimes loose, light green in color, acid in reaction and irritating 



276 SUGAR INDIGESTION 

to the buttocks. They almost never, however, show the marked 
evidences of carbohydrate fermentation so common in the dis- 
turbances of digestion due to an excess of milk sugar in artificial 
foods. 

The disturbance caused by an excessive amount of sugar in 
breast-milk is never a severe one and is not usually of long dura- 
tion. 

It is possible that, if the mother has been taking an excessively 
large amount of sugar, a reduction in the amount of sugar which 
she takes may result in a diminution in the percentage of sugar 
in the milk. If the amount of sugar ingested has been, however, 
within reasonable limits, cutting it down cannot be expected to have 
any effect on the percentage of sugar in the milk. In most instances 
it will be found that she has been eating too much in general rather 
than too much sugar. Cutting down the food as a whole, increas- 
ing the amount of exercise which she takes, and getting her out of 
doors more will ordinarily quickly bring down the percentage of 
sugar to within normal limits. 

Artificial Food. — Indigestion from an excess of carbohydrates 
in an artificial food may be due to the excessive amount of either 
starch or sugar. The sugar at fault may be any one of the sugars 
commonly used in infant feeding, milk sugar, cane sugar or one of 
the dextrin-maltose combinations. The disturbances of the diges- 
tion caused by the various forms of carbohydrates have many 
symptoms in common. Each of them, however, also produces cer- 
tain special symptoms or combinations of symptoms which are 
more or less characteristic. 

Milk Sugar. — Milk sugar in an artificial food seldom causes any 
disturbance of the digestion, unless there is more than 7% of it 
in the mixture. Six per cent, or even 5% will, however, sometimes 
cause trouble in susceptible infants. It is never safe to give more 
than 7% continuously. The disturbances caused by milk sugar 
may be either acute or chronic, but are more often acute. In a con- 
siderable proportion of the cases of indigestion resulting from an 
excess of milk sugar, a part of the symptoms are caused by the prod- 
ucts of the fermentation of the sugar as the result of bacterial ac- 
tion. It is very difficult, and in many instances impossible, to de- 
termine how much of the symptoms are due to the disturbance of 
the digestion of the sugar and how much to the products of ab- 
normal bacterial activity in the sugar. 

The most prominent and characteristic symptom of a disturb- 
ance of the digestion from an excess of milk sugar is the passage of 
loose, or watery, green, acid and irritating stools. They often 



SUGAR INDIGESTION 277 

contain more or less mucus. The odor is distinctly acid. In some 
instances the characteristic odors of lactic, acetic and succinic 
acids may be distinguished. The buttocks and genitals are often 
much excoriated. Vomiting is a less frequent, but is not an uncom- 
mon symptom. The vomitus is acid in reaction, and may also have 
the odor of lactic, acetic or succinic acid. It is usually watery. 
Flatulence and colic are common symptoms. Loss of weight is a 
constant and often a marked symptom in the acute cases; it is usu- 
ally not very marked in the chronic disturbances. The temperature 
often rises rapidly and is not infrequently very high in the more sev- 
ere acute disturbances of digestion resulting from an excess of milk 
sugar. It is seldom of long duration. It is doubtful, however, if 
the rise in temperature is directly due to the absorption of the su- 
gar. It is probable that the explanation is not so simple. The 
temperature is but little, or not at all, elevated in the more chronic 
cases. The symptoms of intoxication may be very marked in the 
more severe acute cases. Among them may be mentioned rest- 
lessness and other manifestations of disturbance of the nervous 
system, marked prostration and disturbance of the respiratory 
rhythm. 

The prognosis in the severe acute cases is grave. If the patients 
survive for forty-eight hours after the onset of the severe symp- 
toms, they usually recover. Improvement is generally rapid after it 
once begins. The prognosis in the chronic cases is good as to life. 
It is usually some weeks or months, however, before the tolerance 
for milk sugar is thoroughly reestablished. It is usually much 
easier, nevertheless, to overcome an intolerance for milk sugar than 
one for fat. 

In the acute disturbances of the digestion from an excess of milk 
sugar, milk sugar must be eliminated as far as possible from the 
food. It must be remembered in this connection that whey con- 
tains between 4.5% and 5% of milk sugar. Whey and whey mix- 
tures are, therefore, contraindicated in this condition. Fat is also 
usually not well tolerated. Small percentages of starch are ordi- 
narily well borne. This is because the starch is broken down slowly 
and because its end-product, dextrose, is quickly absorbed. There 
is, therefore, never much sugar in the intestine at one time. The 
indications are, therefore, for mixtures containing but little fat and 
milk sugar and a considerable amount of protein, with or without 
the addition of starch. Mixtures containing from 0.50% to 1% of 
fat, 1% to 1.50% of milk sugar and 1% to 2% or even 2.50% of 
protein, with from 0.50% to 0.75% of starch are suitable ones. 
Mixtures of skimmed milk with a cereal diluent, in various propor- 



278 SUGAR INDIGESTION 

tions, also meet these indications. It is usually somewhat difficult 
to cover the caloric needs of the infants with mixtures of this 
general character. It is therefore advisable, after a few days, to 
add one of the dextrin-maltose combinations to the mixture, in 
order to bring up its caloric value. It is usually possible to return 
after a short time to milk sugar. Eiweissmilch sometimes works 
very well in these cases. So also do mixtures prepared with pre- 
cipitated casein, because in this way high percentages of protein 
can be given in combination with very low percentages of milk 
sugar. 

Human milk is contraindicated in these cases, because of the 
high percentage of milk sugar which it contains. It is usually well 
borne, however, after the acute symptoms have subsided and in 
convalescence is, as always, the best food. 

In the more chronic disturbances of digestion due to an excess of 
milk sugar, it is advisable to at once cut out all the milk sugar which 
is being added to the food, thus reducing the percentage of milk 
sugar to that which is necessarily put into the food in the cream and 
milk. If the mixture is in other respects a suitable one, the per- 
centages of the fat and protein may be left unchanged. It is often 
advisable, however, to increase the percentage of protein a little, 
in order to bring up the caloric value of the food. The percentage 
of fat may also be increased for the same reason, but this must be 
done cautiously, because there is very likely to be a diminution in 
the tolerance for fat when there is a disturbance in the digestion of 
milk sugar. If the caloric value of the food is still too low, it may 
be increased after a few days by the addition of one of the dextrin- 
maltose combinations. Starch may also be added to the amount of 
0.50% or 0.75%. 

In mild cases it is often possible to gradually put back enough of 
the milk sugar, increasing it 0.50%, or even 1.00%, at a time, to 
cover the caloric needs without causing a recurrence of the symp- 
toms. In such instances it is not necessary to fall back on the 
dextrin-maltose preparations or starch. It is advisable to replace 
the dextrin-maltose preparations by milk sugar as soon as this is 
possible. 

Whey and whey mixtures are contraindicated in these cases, 
because of the high percentage of milk sugar in whey. Eiweiss- 
milch or mixtures prepared with precipitated casein are often 
useful in these cases, because a high percentage of protein may be 
given in this way in combination with a very low percentage of 
milk sugar. One of the dextrin-maltose preparations or starch may 
be added to these mixtures, if desired. 



SUGAR INDIGESTION 279 

Cane Sugar. — The symptoms of disturbance of the digestion, 
whether acute or chronic, from an excess of cane sugar in the food 
are essentially the same as those from an excess of milk sugar. 
Extreme elevations of the temperature in acute disturbances are, 
however, somewhat less common. Babies that get a large amount 
of cane sugar in their food not infrequently show evidences of dis- 
turbance of the nutrition for some time before the appearance of 
the symptoms of disturbance of the digestion. They become fat, 
flabby and pale and their resistance to infection and disease is 
materially diminished. 

The prognosis in disturbances of the digestion due to an excessive 
amount of cane sugar is essentially the same as that in the dis- 
turbances due to milk sugar. It is not quite as good in the chronic 
cases, however, because of the greater disturbance of the nutrition 
produced by the long-continued use of large amounts of cane 
sugar. 

The treatment of disturbances of the digestion due to an exces- 
sive amount of cane sugar is along the same lines as when the 
disturbance is caused by milk sugar. The cane sugar should be at 
once cut out entirely, the percentage of sugar in the food thus being 
reduced to that of the milk sugar which is contained in the cream 
and milk in the mixture. After the symptoms of disturbance have 
ceased the percentage of sugar can then be gradually increased by 
the addition of milk sugar. If the symptoms recur when milk 
sugar is added to the mixture, one of the dextrin-maltose prepara- 
tions can be substituted for it. Starch may also be added in order 
to increase the caloric value of the food. 

Dextrin-Maltose Preparations. — The symptoms of disturb- 
ance of the digestion from an excess of one of the dextrin-maltose 
preparations are similar to those caused by the other sugars. The 
odor of the vomitus is acid, as in the case of the other sugars, but 
this odor is somewhat different, probably because of the presence 
in many instances of butyric acid. Flatulence and colic are usually 
more marked than when the disturbance is caused by the other 
sugars. The stools are usually loose or watery, and dark-brown in 
color, but are sometimes green. The odor is usually a peculiarly 
acrid one. Sometimes, however, it is that of butyric acid. The 
stools are strongly acid in reaction and cause very marked irritation 
of the buttocks, thighs and genitals. The elevation of the tempera- 
ture in acute cases due to an excess of the dextrin-maltose prepara- 
tions is usually less than when they are due to the other sugars. 

The prognosis in the disturbances of the digestion caused by the 
dextrin-maltose preparations is somewhat better than in those 



280 STARCH INDIGESTION 

brought on by the other sugars. The acute disturbances are 
usually rather less severe and both the acute and chronic disturb- 
ances are somewhat more amenable to treatment. 

The treatment of the disturbances of the digestion caused by an 
excess of the dextrin-maltose preparations is along the same lines as 
when the trouble is due to the other sugars. It consists primarily 
in the immediate withdrawal of the preparation. After one or 
two days the preparation may be cautiously added again or, as is 
usually better, milk sugar substituted for it. When an intolerance 
for sugar in general has been established, the caloric value of the 
food may be raised by increasing the percentage of protein in the 
food and adding starch. It must be remembered in this connection 
that the larger the proportion of maltose in these dextrin-maltose 
preparations, the greater, in general, is their laxative action. 
Sometimes, therefore, in the mild chronic disturbances of digestion, 
the substitution of another preparation containing a larger propor- 
tion of the dextrins will relieve the symptoms. 

Starch. — The disturbances of digestion caused by foods com- 
posed entirely of starch are more often chronic than acute. Vomit- 
ing is a relatively uncommon symptom. Flatulence and colic are 
more common. The bowels are sometimes constipated; sometimes 
there is diarrhea. When the bowels are constipated the stools are 
small and brown. In some instances they are dry and crumbly. 
Constipation in these instances is the result of the insufficient 
amount of food, so much of the food being absorbed that there is 
but little left over to form feces. These stools have but little odor. 
Their reaction varies from acid to alkaline, according to whether 
the bulk of the stool is formed from starch remains or from the 
intestinal secretions. 

When the stools are loose the color is brown and they have the 
appearance of mucus. In fact, they are often thought to contain 
mucus or to be composed entirely of mucus. The addition of some 
preparation of iodine to them will, however, turn them dark blue, 
showing that they are composed of unchanged starch and not of 
mucus. If the condition is not severe enough to give the starch 
test macroscopically, it will be plainly visible microscopically. 
These stools are acid in reaction. Their odor is acid, but only 
slightly so. 

The disturbance of the nutrition caused by foods composed 
entirely of starch is far more serious than the disturbances of the 
digestion. This disturbance of the nutrition is due in part to the 
insufficient caloric value of these foods, but far more to their de- 
ficiency in protein and salts. Babies fed exclusively on starchy 



STARCH INDIGESTION 281 

foods may seem to thrive for a time in that they gain in weight, are 
of a fair color, and seem lively and well. Careful examination, even 
at this time, will show, however, that there is an exaggerated mus- 
cular tonicity. This is an early manifestation of the disturbance 
of nutrition. In a few weeks, however, they begin to lose in weight 
and color and their muscles become flabby. If the exclusively 
starchy diet is continued, they gradually take on all the character- 
istics of the starved, atrophic infant. Many of them die of inter- 
current infections, however, before reaching this stage, the resist- 
ance to infection being especially lowered in the disturbances of 
nutrition caused by a diet consisting entirely of starch. 

The prognosis in these cases of chronic disturbance of the diges- 
tion due to an exclusively starchy diet is always a grave one, partly 
because of the marked disturbance of the nutrition and partly be- 
cause of the marked lowering of the resistance to infection induced 
by it. It is always many weeks, and often months, before the dis- 
turbance of the nutrition is entirely overcome. The prognosis in 
the acute cases is very good. They are usually very amenable to 
proper treatment. 

The treatment in the acute cases is the immediate and complete 
withdrawal of the starchy food. A modified milk, in which the per- 
centages are all low and in which the relation of the fat, milk sugar 
and protein to each other are similar to those in human milk, can 
usually be given at once. Examples of such mixtures are: 

Fat 1.00% 

Milk Sugar 4.00% 

Protein 0.75% and 

Fat.... 2.00% 

Milk Sugar 5.00% 

Protein 1.26% 

Whey and whey mixtures are often useful under these conditions. 

The treatment in the chronic cases is along the same lines. It is 
more difficult to fit the food to the digestive capacity in these cases, 
however, because the functions of the digestion and metabolism of 
fat and protein have usually been materially weakened by disuse 
and by the impairment of the nutrition. It is always advisable in 
these cases, therefore, to give human milk, if it can possibly be ob- 
tained. 

The disturbance of the nutrition when the purely starchy foods 
are partially dextrinized is as great as when they are not. The 
symptoms of disturbance of the digestion from starch are, however, 



282 STARCH INDIGESTION 

diminished, although those from an excess of malt sugar may take 
their place. When the dextrin-maltose preparations or other 
sugars are added to the starchy foods their caloric value is in- 
creased and to this extent the disturbance of the nutrition is di- 
minished. That due to the deficiency of protein and salts is, how- 
ever, unaffected. The symptoms of disturbance of the digestion 
caused by these sugary and starchy foods are a combination of 
those due to an excess of starch and of those due to an excess of 
sugar. The symptoms caused by the excess of sugar usually pre- 
dominate. 

When starch is added in excess to a food of which milk forms the 
basis it causes but little disturbance of the nutrition and relatively 
little disturbance of the digestion. It seldom causes vomiting, but 
not infrequently causes flatulence and colic. It sometimes makes 
the stools harder and drier. It more often causes a looseness of the 
bowels. The stools are more acid than normal, have an acid odor 
and irritate the buttocks. The undigested starch may be visible 
in the movements and may be mistaken for mucus. If it is visible, 
it will turn dark blue when a preparation of iodine is added to the 
stool. If it is not visible macroscopically, it can be found in all 
cases microscopically. It is almost invariably associated with the 
presence of numerous iodophilic bacteria. These organisms are 
often found, moreoever, before starch itself can be detected and, 
when found, they always suggest that a disturbance of the diges- 
tion from starch is imminent. 

Disturbance of the digestion from starch is much less likely to 
occur, if the starch is thoroughly cooked. It almost never de- 
velops unless there is 1% or more of starch in the mixture. 

The prognosis of the disturbances of digestion caused by an ex- 
cess of starch in mixtures the basis of which is milk is good. Re- 
covery is ordinarily prompt when the cause is removed. 

The treatment consists in cutting the starch entirely out of the 
food for a time. It can ordinarily be put back in reasonable amounts 
after a short time. The trouble will seldom recur, if the percentage 
of starch is not over 0.75%. 

INDIGESTION FROM AN EXCESS OF PROTEIN 

Breast-Milk. — Indigestion from an excess of protein in human 
milk is much more common than from an excess of either fat or 
milk sugar. The protein is more likely to be excessive during the 
early part of lactation, before the equilibrium of the milk has been 
established and the mother has resumed her normal life, than later. 
The excess of protein may be due to anxiety or nervousness on the 



PROTEIN INDIGESTION 283 

part of the mother, or to either fatigue or lack of exercise, all of 
which increase the protein content of the milk. It is impossible to 
know in advance what percentage of protein will be an excess for 
the individual infant. Some babies are disturbed if the protein is 
more than 1.50%, while others can take 2.50% or even 3.00% 
without being disturbed in any way. 

Vomiting, while it does occur, is a comparatively uncommon 
symptom of indigestion from an excess of protein in breast-milk. 
Flatulence and colic, on the other hand, are very common symp- 
toms and are often very marked and very troublesome. There is 
almost invariably an increase in the number of the stools, which are 
either loose or watery. They are usually brownish-yellow instead 
of golden in color, but may be green. They not infrequently con- 
tain mucus and often fine, soft, fat curds. These may be due to a 
coincident fat indigestion, but are more often due to the increased 
peristalsis and consequent interference with absorption. The 
reaction is alkaline or feebly acid. The odor is not characteristic. 
It may be acid or a little foul. The stools do not ordinarily irritate 
the buttocks. The temperature may be slightly elevated, but 
ordinarily is not. In some instances, however, when the disturb- 
ance is an acute one from a sudden and marked increase in the per- 
centage of protein, the temperature may be considerably elevated. 
The nutrition is not as much affected as would be expected from the 
amount of digestive disturbance. There is ordinarily not much 
loss of weight. Many babies continue to gain, although slowly, 
while occasionally a baby will gain rapidly in spite of much colic 
and many loose stools. 

Disturbance of the digestion from an excess of protein in breast- 
milk is usually rapidly recovered from, if the cause of the excess can 
be removed. The results are seldom lasting. In rare instances, 
however, when there is a sudden and very marked increase in the 
percentage of protein, the babies may die within a few days. It is 
possible, however, that the cause of death in such cases may not 
be the excessive amount of protein but some unrecognizable chem- 
ical change in the milk. 

The treatment of indigestion from an excess of protein in breast- 
milk consists primarily in regulation of the mother's diet and life 
in order to reduce the percentage of protein in the milk. When the 
percentage of protein is excessive, while the percentages of fat and 
sugar are within normal limits, but little can be done to diminish 
the percentage of protein alone. Diminishing the relative propor- 
tion of protein in the diet should, however, be tried. When the 
percentages of fat and sugar, as well as that of the protein, are high, 



284 PROTEIN INDIGESTION 

it is possible to reduce them all simultaneously to a certain extent 
by cutting down the amount of food and increasing the amount of 
exercise which the mother takes. Increasing the length of the in- 
tervals between the nursings will also diminish the percentage of 
protein together with those of the other elements. The percentage 
of protein may also be diminished by giving the baby water at the 
time of the nursing. The percentages of fat and sugar are, how- 
ever, also diminished to the same extent. 

When the high percentage of protein is the result of inactivity on 
the part of the mother, it can be diminished by making her take 
more exercise. Exercise in the open air is preferable to that in- 
doors. Care must be taken, however, that she does not take too 
much exercise and become fatigued, because fatigue increases the 
protein. If the excess of protein in the milk is due to fatigue or 
overwork, it can be diminished by resting the mother and keeping 
her more quiet. 

When the high percentage of protein is due to nervousness, 
worry or anxiety, the remedy is obvious. The removal of the 
cause will at once result in a diminution in the percentage of 
protein. It is, however, unfortunately, seldom possible to modify a 
woman's natural temperament and frequently very difficult to 
remove causes of anxiety and worry. 

Artificial Food. — A disturbance of the digestion is almost never 
due to an excess of protein in an artificial food, unless that food is 
cow's milk or some modification of cow's milk. When there is a 
disturbance of the digestion as the result of an excess of the protein 
in cow's milk, the excess is almost invariably of casein, not of whey 
protein. 

Whey Protein. — When babies that are being fed on whey or on 
mixtures containing a high percentage of whey protein have a dis- 
turbance of the digestion, this disturbance is in the vast majority 
of instances due to the milk sugar and salts in the whey rather than 
to the whey protein itself. The symptoms are, therefore, those of 
an excess of milk sugar and of salts. It is probable, however, that 
in rare instances the whey proteins may cause a disturbance of the 
digestion. The chief symptom of such a disturbance of the diges- 
tion is the presence of an increased number of loose, watery stools. 
There may also be flatulence and colic. The stools may be normal 
in character, except for their diminished consistency, but are some- 
times brownish and alkaline, with a musty odor. 

The disturbance of the digestion from an excess of whey 
protein is usually not a severe one and ordinarily yields promptly 
to proper treatment. 



PROTEIN INDIGESTION 285 

The treatment of a disturbance of the digestion from an excess of 
whey protein consists in stopping the whey or diminishing the per- 
centage of whey protein, and giving the necessary percentage of 
protein in the form of casein. 

Casein. — The symptoms of disturbance of the digestion from an 
excess of casein are vomiting, flatulence and colic, abnormal stools, 
somnolence and disturbance of the nutrition. The vomitus often 
contains very large curds. These curds may be fairly soft or tough 
and leathery. The vomitus ordinarily has but little odor. It may 
smell slightly acid, but is never strongly acid. Flatulence and colic 
are often quite severe. The chief abnormality in the stools is the 
presence of large, hard curds. The number of stools may or may 
not be increased. In many instances the stools are normal in char- 
acter, except for the presence of the curds. In other instances, how- 
ever, there may be an increased number of loose or watery stools, 
brownish in color and alkaline in reaction. The odor is musty. 
These stools at times contain an excess of mucus, but almost never 
curds. The disturbance of the nutrition from an excess of casein in 
the food is usually not very marked. There is ordinarily no fever, 
but in some instances the temperature is moderately elevated. 
If the temperature is high, it is probably due to some other 
cause, such as an excess of salts. 

The prognosis of disturbances of the digestion caused by an ex- 
cess of casein is usually good. It is not a difficult matter, in most 
instances, to correct the disturbance by diminishing the percentage 
of casein or by the use of one of the numerous methods for prevent- 
ing the formation of large casein curds. 

When the disturbance of the digestion of protein results in the 
passage of watery, brown, musty stools, the protein must be cut 
entirely out of the diet for a time and some form of carbohydrate 
be given in its place. Any of the cereal waters, to which milk sugar 
or one of the dextrin-maltose preparations may be added, is suit- 
able. Protein, best in the form of casein, must be added again as 
soon as possible, however, in order to prevent serious disturbance 
of the nutrition from the loss of body protein as the result of the 
lack of protein in the food. 

When the disturbance of digestion shows itself by the vomiting 
of large curds, flatulence and colic, and the passage of large, hard 
curds in the stools, the object of the treatment is to prevent the 
formation of large curds in the stomach. If they are not formed 
there, they will not be formed lower down. If the formation of 
large curds can be prevented, the casein will, in most instances 
cause no disturbance. The simplest way to prevent the formation 



286 PROTEIN INDIGESTION 

of large casein curds is to diminish the percentage of casein in the 
milk mixture. When this plan is adopted, great care must be taken 
not to diminish the percentage of protein so much that the protein 
need of the baby is not covered. 

A portion of the protein may be given in the form of whey pro- 
tein. In this way the formation of large curds is prevented and 
yet the protein need of the baby can be covered. There are many 
methods for preventing the formation of large casein curds. These 
methods are very different, but the result obtained with all of them 
is the same. In some way or other the production of large casein 
curds is prevented or at least hindered. Some of these methods are 
boiling the milk, the addition of cereal diluents, the addition of 
lime water or other alkalis to the mixture, the addition of citrate of 
soda, and "peptonization" of the milk. Another way of prevent- 
ing the formation of large casein curds is by using buttermilk. Still 
another way is by the use of precipitated casein in the milk mix- 
tures, or in the form of Eiweissmilch. It is often very hard to de- 
cide which method to use in a given case. A careful study of the 
conditions in the case and a thorough comprehension of the way in 
which the formation of casein curds is prevented in each method 
will usually show, however, which one is the most suitable one un- 
der the circumstances. These methods are fully described on pages 
202 to 205. 

INDIGESTION FKOM AN EXCESS OF SALTS 

There is no doubt that the salts play a most important part in 
the metabolism of the other food elements and that the metabolic 
processes cannot progress normally unless the proper salts are pres- 
ent in the proper proportions. There is unquestionably a dis- 
turbance of the metabolism of the salts in all disturbances of nu- 
trition in infancy. It is very difficult to determine, however, 
whether the disturbance of the nutrition in any given case is due 
primarily to a disturbance of the salt metabolism from an in- 
sufficiency or improper combination of the salts in the food or 
whether the disturbance of the salt metabolism is secondary to an 
insufficiency, excess, or improper combination of one or more of 
the other food elements and to the disturbance of the digestion 
caused by them. 

There is no doubt, moreover, that the salts play an important 
part in every digestive disturbance in infancy. It is probable, but 
not certain, that the salts may of themselves cause disturbance of 
the digestion independently of the other food elements. Very 
little is known as to the symptoms which an insufficiency or an ex- 



INDIGESTION FROM SALTS 287 

cess of the salts as a whole in the food may cause. If the salts are 
cut out of a food, which is otherwise unchanged, the weight falls. 
When they are put back again, the weight rises. This variation in 
the weight is probably largely, but not entirely, due to variations 
in the retention of water. The sodium salts favor the retention of 
water. The salts of calcium diminish its retention to a moderate 
extent. It is also known that the withdrawal of salts from the food 
results in a lowering of the body temperature. An excess of cal- 
cium in the food also lowers the temperature. If a large amount of 
sodium chloride is given to a baby suffering from a disturbance of 
the digestion, there is usually a rise in the temperature. If there is 
no disturbance of the digestion, there is ordinarily no elevation of 
the temperature. Variations in the weight and temperature are, 
however, common to all disturbances of the digestion and do not, 
therefore, justify the diagnosis of indigestion as the result of some 
abnormality in the salts of the food. There being no symptoms 
peculiar to abnormalities in the salts of the foods, it is, therefore, 
impossible at present to make a diagnosis of indigestion from an 
excess or from an improper combination of the salts in the food. 
The condition may be suspected, but that is all. 

It being impossible to make a positive diagnosis of indigestion 
from an excess or an improper combination of the salts in the food, 
it is evidently impossible to make a definite prognosis or to lay 
down any rules for treatment. 

The Medicinal Treatment of Disturbances of the Digestion 
in Infancy. — The treatment of the disturbances of digestion in in- 
fancy consists primarily in regulation of the diet. All other 
methods of treatment are relatively unimportant. They have their 
place, however, and cannot be dispensed with. They are especially 
useful for the relief of symptoms. 

In the first place, the bowels should be throughly cleaned out 
in every acute disturbance of the digestion, whatever its cause, 
unless this disturbance is very slight. The most useful drug for 
this purpose is castor oil, because it is effective, acts quickly and 
causes less irritation, of the bowels than calomel and strong salines. 1 
The dose should be from one to three teaspoonfuls, according to 
the age of the baby and the effect desired. Babies do not, as a 
rule, object to the taste of castor oil. In fact, most babies like it. 
No attempt should be made, therefore, to disguise its taste. The 
stools produced by castor oil always contain mucus. Too much 
importance must not be attached, therefore, to the presence of 
mucus in the stools after a dose of castor oil. 

1 Abt. Archives of Pediatrics, 1909, xxvi, 836. 



288 MEDICINAL TREATMENT 

If less vigorous catharsis is desired than that usually produced 
by castor oil, milk of magnesia may be used in its place. The 
dose is from one to three teaspoonfuls, according to the age of 
the baby and the effect desired. It may be given in the food, plain, 
or diluted with water. 

Castor oil should be tried first, even if the baby is vomiting. 
It will often be retained when food is vomited. If it is vomited, 
calomel may then be tried. It is best given in doses of one-tenth 
of a grain combined with one grain of bicarbonate of soda, every 
half-hour, until one grain has been taken. It is advisable, but not 
necessary, to give one or two teaspoonfuls of the milk of magnesia 
three or four hours after the last dose of calomel. It should not be 
forgotten that calomel often gives the stools a peculiar green color 
that may be mistaken for that resulting from disturbances of the 
digestion in which the stools are excessively acid. 

If the disturbance of the digestion is acute, severe and associated 
with considerable elevation of the temperature, it is also advisable 
to wash out the colon with salt solution or at least to give an enema 
of suds to clean out the bowel from below. 

When the disturbance of the digestion is a chronic one, it is, as a 
rule, inadvisable to begin treatment with an initial catharsis. 
Catharsis is a weakening procedure and, when a baby is in a debili- 
tated and feeble condition as the result of a long disturbance of 
the nutrition, is liable to do serious injury. When the disturbance 
of nutrition is extreme it may, in fact, take away the baby's last 
chance of recovery. 

When babies with acute disturbances of digestion are vomiting, 
all food should be stopped. They may be given water to which 
bicarbonate of soda, in the proportion of one level teaspoonful to 
eight ounces of water, has been added, in teaspoonful doses, every 
ten to thirty minutes. If the vomiting is severe or persistent, the 
stomach should be washed out once or twice daily with a solution 
of bicarbonate of soda of the strength of one rounded teaspoonful 
to a pint of water. 

It is not a difficult matter to wash out the stomach of a baby. 
There is usually no difficulty in introducing the catheter, even in 
the youngest baby. A soft rubber catheter, No. 16, American 
scale, or one a little smaller is used. The catheter should be at- 
tached by a short piece of glass tubing to a rubber tube attached 
to a funnel. The baby should be well wrapped up and it and the 
nurse protected by a rubber apron or sheet. The baby should be 
held upright in the nurse's lap, facing forward and bending a little 
forward. The mouth can be held open by the forefinger of the 



MEDICINAL TREATMENT 289 

left hand, around which a towel may be wrapped. The catheter, 
which is held in the right hand, is then pushed to the back of the 
throat and downward. It passes most easily when the baby gags. 
The distance from the gums or incisor teeth to the cardia during 
infancy is between seven and eight inches. The catheter should, 
therefore, not be introduced farther than this. It is very difficult 
to pass the catheter anywhere except into the esophagus. It is 
possible, however, to pass it through the larynx. Water should 
never be poured in, therefore, until the baby has cried clearly or 
food has come up through the tube. It is easier to start the si- 
phonage if the tube is introduced full of water. The washing should 
be continued until the water returns clear. 

It is rarely necessary or advisable to give an emetic to in- 
fants suffering from disturbances of the digestion. A teaspoon- 
ful of the wine of ipecac is the safest and best, if an emetic is 
necessary. 

The best treatment for the flatulence and colic associated with 
disturbances of digestion is the removal of the cause. This is done 
by regulation of the diet. While the cause is being removed, the 
symptoms must, however, be relieved, if possible. It is advisable 
to try the simplest remedies first. These are hot applications to the 
abdomen and hot water by the mouth. If these measures are not 
effective, a quarter or a half of a soda mint tablet dissolved in an 
ounce of hot water may be tried, or from two to five drops of the 
essence of peppermint in the same amount of hot water. Five or 
ten drop doses of the elixir of catnip and fennel (Wyeth's) in one or 
two tablespoonfuls of hot water are sometimes useful. An enema 
of warm water will almost always stop the colic if other measures 
fail. It is very seldom necessary or advisable to use any form of 
alcohol or paregoric. Flatulence and colic are often due to the 
swallowing of air during the act of nursing, whether from the 
breast or bottle. The swallowed air tends to collect in the fundus. 
After the stomach is partially full the air cannot reach and be 
discharged through the cardiac orifice. If the baby is picked up 
from time to time during the nursing, held upright and its back 
patted, the air can escape and the flatulence and colic will be pre- 
vented. 

There is little or no place for the so-called "digestants" in the 
treatment of disturbances of digestion in infancy. There is almost 
never a deficiency of either pepsin or hydrochloric acid in the gas- 
tric secretion and rennin is always present. The panreatic fer- 
ments cannot pass through the stomach without being destroyed. 
The only place for the digestive ferments in the treatment of these 



290 MEDICINAL TREATMENT 

conditions is, therefore, in predigesting the foods before they are 
taken by the infant. 

There is little or no absorption of fat through the skin, certainly 
not enough to have any appreciable effect on the nutrition. The 
only way in which inunctions of cod liver or other oils in chronic 
disturbances of nutrition can be of use, therefore, is through the 
stimulation of the peripheral circulation and muscular tone in- 
cident to the rubbing. 

It is advisable to stop the food entirely for from twelve to forty- 
eight hours in all the acute disturbances of digestion from whatever 
cause. There is no danger in stopping the food, if the baby is given 
as much water as it would take of food. Babies can get along very 
well for a time without food, but they cannot get on without water. 
If they object to plain water, they will usually take it gladly if it is 
sweetened with saccharin. There is no objection to giving it in the 
form of very weak tea, sweetened with saccharin, if the babies like 
it better in this way. The length of time during which food is 
withheld depends on the severity of the symptoms in the given 
case. 

Great care must be exercised in stopping the food of babies 
suffering from chronic disturbances of the nutrition, even when 
there is an acute exacerbation of the symptoms. Such babies are 
in no condition to bear acute starvation on top of a chronic inani- 
tion. In fact, the complete withdrawal of food is very likely to 
kill them. It is much wiser, therefore, under these conditions, to 
weaken or change the food than to stop it entirely. 



CHAPTER XXIV 
INDIGESTION WITH FERMENTATION 

The term, indigestion with fermentation, is used to distinguish a 
condition in which fermentation takes place in the intestines as the 
result of the abnormal growth and activity of microorganisms in the 
intestinal contents. The term fermentation is used here in its 
broad sense and includes all the changes which take place in the 
various food elements as the result of the action of microorganisms 
upon them. In some instances the microorganisms concerned are 
the normal inhabitants of the intestinal tract, in others they do not 
belong to the normal intestinal flora. 

It is extremely difficult to draw a distinct line between simple 
indigestion and indigestion with fermentation on the one hand and 
between indigestion with fermentation and infectious diarrhea on 
the other. It is assumed in the first instance that there is no 
fermentation in simple indigestion. This assumption is, of course, 
not strictly true, because there is unquestionably a certain amount 
of fermentation under normal conditions and more in simple in- 
digestion. In simple indigestion, however, the fermentation plays 
but a small part in either the pathology or symptomatology of the 
condition and none in the etiology. In indigestion with fermenta- 
tion, however, fermentation plays the major role. Whether the 
abnormal bacterical activity develops secondarily as the result of 
disturbances of the normal processes of digestion or appears 
primarily as the result of the introduction of an excessive number 
of bacteria, whether or not they are members of the ordinary intes- 
tinal bacterial flora, into the intestine or as the result of a change in 
the normal relations of the bacteria to each other from a badly bal- 
anced diet, the symptoms are due in the main to the presence of the 
abnormal products of bacterial activity. It is assumed in the 
second instance that in indigestion with fermentation there are no 
pathological lesions in the intestinal wall and that no micro- 
organisms pass from the intestines into the general circulation. 
These assumptions are also not strictly true, because there are, 
without doubt, some minor changes in the intestinal wall in severe 
cases of indigestion with fermentation and it is presumable that 
an occasional microorganism enters the blood stream. The in- 

291 



292 ETIOLOGY 

testinal lesions are, however, never marked, in contradistinction 
to the severe lesions characteristic of infectious diarrhea. It is 
presumable, moreover, although not proven, that in infectious 
diarrhea microorganisms frequently pass into the circulation, per- 
haps in considerable numbers. 

Etiology. — So little is known accurately as to the normal intes- 
tinal flora and as to the normal variations in the relation of the in- 
dividual elements of this flora to each other as the result of changes 
in the relative proportions of the various food elements, that it 
is extremely difficult to draw any positive conclusions from the 
microscopic examination of the stools, not only as to what organ- 
ism or organisms are causing the trouble in a given case, but also 
as to what organisms may in general cause excessive fermentative 
changes. Furthermore, it is by no means always safe to draw posi- 
tive conclusions as to the intestinal bacteria from an examination of 
the fecal bacteria. There is a certain amount of fairly satisfactory 
evidence to show that butyric acid bacilli, the B. acidophilus, and 
the B. putrificus may cause abnormal fermentative changes in 
the intestinal contents. It is probable that under certain condi- 
tions the colon bacillus may also be the cause of abnormal fer- 
mentative processes. The unrestrained and excessive activity of 
the normal lactic acid forming organisms of the intestinal flora may 
also result in an excessive acid fermentation sufficient to cause def- 
inite and severe symptoms. The B. perfringens, described by Tis- 
sier * has been proved more positively than any other organism to 
be the cause of fermentative diarrhea. 

Pathology. — The pathological changes in the intestine in indiges- 
tion with fermentation are comparatively slight. In most in- 
stances there is presumably nothing more than an injection of the 
mucous membrane, while in the most severe cases the process does 
not progress beyond that of a mild catarrhal inflammation. 

In the more severe cases of indigestion with fermentation there 
are more or less marked degenerative changes in the parenchy- 
matous organs, especially in the liver and kidneys. True inflam- 
mation of the kidneys is, however, uncommon. Secondary infec- 
tions of other organs, such as the middle ears and lungs, as the 
result of the general weakened resistance, are not uncommon in 
the serious cases. 

Symptomatology. — Indigestion with fermentation is more often 

acute than chronic. When it is acute, there is in most instances 

some elevation of the temperature. The height of the temperature 

depends presumably on the amount of toxic absorption. In the 

1 Annales de l'lnstitut Pasteur, 1905, xix, 273. 



SYMPTOMATOLOGY 293 

most severe cases it may be as high as 104° F. or 105° F., or even 
higher. Such high temperatures do not, however, usually last 
more than three or four days, although the temperature may be 
moderately elevated for some days longer. The temperature is 
ordinarily but little, if at all, elevated in the chronic cases. 

The appetite is usually impaired. Vomiting is unusual, and 
there is nothing characteristic about it, when it does occur. There 
is usually more or less abdominal discomfort, and the abdomen is 
not infrequently distended. There is, of course, always more or 
less loss of weight. 

Diarrhea is a marked symptom in almost all cases of indigestion 
with fermentation. The character of the stools depends upon 
which of the food elements is being attacked by the microorgan- 
isms which are the cause of the trouble in the individual case. 
In the vast majority of instances indigestion with fermentation is 
due to organisms which produce fermentative changes in carbo- 
hydrates and to a less extent in fats. The stools are, therefore, 
usually green in color, strongly acid in reaction and odor, and ir- 
ritating to the skin. They often contain a considerable amount of 
mucus, as the result of the irritation of the intestinal mucosa by 
the highly acid intestinal contents. They are often frothy and not 
infrequently contain many small, soft, fat curds. When the dis- 
ease is caused by the abnormal activity of proteolytic organisms 
the stools are more often yellow or yellowish-brown than green. 
They are ordinarily alkaline in reaction and have a foul odor. They 
seldom contain curds, and mucus is a less prominent constituent. 
In one type of this class of cases the stools are rather character- 
istic, being frequent, small, watery, dark-brown, alkaline and with 
a peculiar musty odor. 

There is almost always a moderate polynuclear leucocytosis in 
these cases, if they are at all severe. It is ordinarily not over 
20,000, but in the severest cases may be much higher. In them, 
however, the toxemia may be so great that the system is over- 
whelmed. In such instances there is no leucocytosis. 

The urine is usually diminished as the result of the loss of fluid 
through the bowels and the diminution in the intake. In the se- 
vere cases it not infrequently shows the evidences of acute degen- 
eration of the kidneys. Acute inflammation of the kidneys is very 
unusual. The urine rarely contains sugar, unless the toxemia is 
extreme or very large amounts of sugar are being ingested. 

In the most severe and fatal cases certain symptoms, such as un- 
controllable vomiting, marked prostration and hyperpyrexia, are 
likely to develop. In others there may be marked symptoms of ir- 



294 DIAGNOSIS 

ritation of the nervous system. These symptoms are in all prob- 
ability due largely to toxic absorption from the intestines. They 
are more fully described in the chapter on Infectious Diarrhea, in 
which disease they also frequently develop. 

Diagnosis. — The two conditions with which indigestion with 
fermentation may be confused are simple indigestion and infectious 
diarrhea. It is often very difficult to distinguish between simple 
indigestion and indigestion with fermentation, because of the fact 
that all but the mildest cases of simple indigestion are accom- 
panied by a certain amount of fermentation in the intestinal con- 
tents as the result of bacterial activity in them. The border line 
between them is, therefore, a very indefinite one and must often 
be arbitrarily drawn. The manifestations of simple indigestion of 
the various food elements are, moreover, very similar to those of 
fermentation of these same elements as the result of abnormal bac- 
terial action. This makes it still more difficult to draw the line. 
It has to be drawn principally on the relative severity of the symp- 
toms in general and especially on the degree of the evidences of 
fermentation. When these predominate the picture, the diagnosis 
of indigestion with fermentation is justified. In general, moreover, 
the constitutional symptoms are more severe, the temperature 
higher, and the manifestations of toxemia more marked in indiges- 
tion with fermentation than in simple indigestion. 

Mild or moderately severe cases of indigestion with fermenta- 
tion are not likely to be confused with infectious diarrhea. The 
more severe cases, with high fever, marked evidences of toxic ab- 
sorption and considerable amounts of mucus in the stools may, how- 
ever, be mistaken for it. It is very often difficult to differentiate 
between them and it is not infrequently impossible to make a posi- 
tive diagnosis. The most important single symptom in the di- 
agnosis is probably the temperature curve, the elevation of tem- 
perature in severe cases of indigestion with fermentation being, as 
a rule, high and of short duration, while in infectious diarrhea, al- 
though not usually very high, it is constant and continuous. The 
stools show, in general, more evidences of fermentation in indiges- 
tion with fermentation than in infectious diarrhea, and never 
contain blood, as they do in infectious diarrhea. In a certain 
number of instances, however, a positive diagnosis can only be 
made by a bacteriological examination of the stools. 

Prognosis. — The outlook is always grave in the cases which 
show marked evidences of toxic absorption. If they survive the 
first three or four days, however, they usually recover. Those 
cases in which the stools are watery and dark brown with a musty 



TREATMENT 295 

odor are also always serious. The cases in which the evidences of 
carbohydrate fermentation predominate are usually milder than 
the other types and yield fairly readily to rational treatment. A 
high temperature is not, of itself, of especially bad prognostic im- 
port. Neither are the presence of considerable amounts of mucus 
in the stools or of albumin and other evidences of degeneration of 
the kidneys in the urine. The cases which have become chronic 
are likely to drag along for a long time in spite of careful treatment. 

Treatment. — It is advisable in all acute cases of indigestion with 
fermentation to at once thoroughly clean out the intestinal tract. 
The best drug for this purpose is castor oil. It works quickly, 
thoroughly and causes less irritation of the intestines than other 
cathartics. The dose should not be less than two teaspoonfuls. 
It should be given plain. If the castor oil is vomited, calomel 
should be given in its place. The usual dose is T V of a grain, com- 
bined with one grain of bicarbonate of soda, every half-hour until 
1 or V/2 grains have been given. It is wise to follow it with two or 
three teaspoonfuls of the milk of magnesia in two or three hours 
after the last dose. This treatment should be repeated, if the 
desired results are not obtained. 

All food should be stopped for from twelve to twenty-four hours. 
It is not desirable, as a rule, to withhold food longer than this. It is 
necessary, however, to give water freely during this period, be- 
cause, although a baby can bear temporary starvation, it cannot 
get along without water. At least as much water should be given 
as the baby would ordinarily take of liquid in the form of food in 
the given time. The water may be given either warm or cool, 
and may be sweetened with saccharin, if desired. There is no 
objection to giving it in the form of weak tea, sweetened with 
saccharin, if it is taken better in this way. It should be given 
through a tube, if the baby will not take it otherwise. It is not 
safe to continue the period of starvation longer than twenty-four 
hours when the microorganisms which are causing the trouble are 
of the proteolytic type, because the intestinal secretions are protein 
in nature and, therefore, provide a suitable culture medium for 
proteolytic bacteria. There is no objection to a longer period of 
starvation when the microorganisms are of the types which thrive 
on fats and carbohydrates, if it is for any reason indicated. Pre- 
liminary purgation and starvation are rarely advisable in chronic 
cases. 

The object to be aimed at in the treatment of indigestion with 
fermentation is the destruction, or at least the inhibition of the 
activity, of the microorganisms which are the cause of the disease. 



296 TREATMENT 

It is useless to attempt to do this by the administration of drugs by 
the mouth, because it is impossible to give any of the so-called 
intestinal antiseptics in large enough doses to have any effect on 
the pathogenic bacteria in the intestine without poisoning the 
baby. If they did have any action, it would be exerted, moreover, 
on the antagonistic as well as on the pathogenic bacteria. They 
would be likely, therefore, to do as much harm as good. It is 
possible that the salts of bismuth may diminish the intensity of the 
symptoms to a small extent. They do not have, however, any 
curative action. If they are used, they should be given in doses of 
from ten to twenty grains, every two hours. It is safer to use the 
subcarbonate or the milk of bismuth than the subnitrate, because 
of the danger of nitrite poisoning when the subnitrate is used. It 
is also useless to attempt to get rid of the pathogenic bacteria by 
irrigation of the bowels, because the fluid used in irrigation never 
reaches higher than the ileocecal valve, if it reaches as far as that, 
while the chief seat of the trouble is in the small intestine. 

It is possible in some instances to destroy the pathogenic micro- 
organisms, or at any rate to materially diminish their numbers 
and inhibit their activity, by the administration of antago- 
nistic bacteria. This method has been proved to be effectual when 
the disturbance is due to the B. perfringens and organisms of the 
gas bacillus group. There is some evidence to show that it is of 
value when the trouble is caused by the B. acidophilus and proteo- 
lytic organisms. Tissier has shown that the B. bifidus has an 
antagonistic action on the B. perfringens. It is probable that it has 
a similar action on other pathogenic organisms. It is, however, 
anaerobic and, therefore, difficult of cultivation. Its use is, on this 
account, hardly practicable clinically. Lactic acid bacilli have, 
however, an antagonistic action on all the organisms mentioned. 
It is easy to obtain them in pure cultures and in any amounts 
desired. It is probable that the Bulgarian bacillus has some ad- 
vantages over the other varieties. The lactic acid bacilli may be 
given in the form of broth cultures, in the form of buttermilk or in 
the form of modified milk ripened by them. They are effective 
when given in any of these ways. It seems most rational, however, 
to give them in the form of ripened modified milk, because when 
given in this way the food can also be modified to suit the needs of 
the individual infant. There is a certain advantage in the use of 
buttermilk and ripened modified milk over broth cultures of the 
lactic acid bacilli, in that they contain, in addition to the organ- 
isms, lactic acid which has been formed by them. This, in itself, 
has an antagonistic action on the growth of the pathogenic organ- 






TREATMENT 297 

isms. When buttermilk and ripened modified milk are used in 
the treatment of indigestion with fermentation, they should not be 
pasteurized or boiled, because, if they are, the lactic acid organ- 
isms are killed and can, therefore, have no effect. It is self- 
evident that, when lactic acid bacilli are the cause of the fermenta- 
tion, foods containing these organisms should not be given. 

Another way by which the number of the organisms causing 
indigestion with fermentation can be diminished and their activity 
inhibited is by a change in the character of the infant's food. A 
change in the character of the food results in a change in the 
character of the intestinal contents, that is, in the medium in which 
the pathogenic organisms are growing. If these are of the types 
which thrive on a carbohydrate medium, the percentages of the 
carbohydrates should be diminished and that of the protein in- 
creased. The percentage of fat should also be diminished, because 
when there is an abnormal fermentation of the carbohydrates there 
is very likely to be a secondary fermentation of the fat. When the 
organisms are of the butyric acid forming type the percentage of fat 
should be much diminished, that of the carbohydrates diminished 
to a moderate degree and that of the protein increased. When the 
organisms are proteolytic, the percentage of protein should be 
diminished and that of the carbohydrates increased. The general 
principles to be followed as to the choice of carbohydrates in dis- 
turbances of the digestion which have been described in the chapter 
on indigestion are equally applicable in the treatment of indiges- 
tion with fermentation. It is evident that in certain instances it is 
possible to combine both methods of treatment. 

Sisson * has come to the conclusion, however, as the result of 
his experiments on puppies, that it is not possible to change the 
character of the intestinal flora by changes in the diet. Rettger 2 
has arrived at a different conclusion, as have also previous investi- 
gators. It hardly seems wise, therefore, to accept Sisson's results 
until they have been verified by others. 

Clinically, when the stools are loose, green, acid and irritating, 
the percentage of fat and carbohydrates in the food should be re- 
duced and that of the protein raised. It is in cases of this type that 
"albumen milk" gives such satisfactory results. So also do mix- 
tures made with a high percentage cream and dried casein. Beef 
juice, broths and albumen water may also be given. When a for- 
eign protein is given under these conditions, there is always a pos- 
sibility that it may pass through the intestinal wall unchanged and 

1 Sisson: Amer. Jour. Dis. Child., 1917, xiii, 117. 

2 Rettger: Jour. Exp. Med., 1915, xxi, 365. 



298 TREATMENT 

sensitize the baby. This is especially liable to happen with 
albumen. Albumen water should, therefore, always be used cau- 
tiously, if at all, in the treatment of the diarrheal diseases of in- 
fancy. Unless the fermentation is due to lactic acid bacilli, 
buttermilk and ripened modified milk mixtures, containing low 
percentages of fat and carbohydrates and a high percentage of pro- 
tein, give better results than similar modifications unripened. If 
the fermentation is due to the lactic acid bacilli, the simple modi- 
fications give, of course, much more satisfactory results. 

When the stools are brownish, alkaline and foul, the percentage 
of protein should be much reduced and that of the carbohydrates 
much increased. That of the fat should be kept low. Protein 
foods, such as beef juice, broth and albumen water should not be 
given. Buttermilk and ripened modified milk mixtures containing 
a low percentage of fat and protein and high percentages of car- 
bohydrates usually give good results. So also does breast-milk. 

Babies that are seriously ill with indigestion with fermentation 
are very likely to show one or more rather characteristic symptoms 
or groups of symptoms. One of these groups of symptoms almost 
invariably develops toward the end in fatal cases. These symp- 
toms are: 

(a) Excessive vomiting. 

(b) Hyperpyrexia. 

(c) Symptoms of irritation of the central nervous system. 

(d) Prostration and collapse. 

It is probable that these symptoms are chiefly manifestations of 
toxemia. It is presumable that the loss of water through the 
bowels also plays a part in their production. These symptoms also 
develop very frequently in infectious diarrhea. They and the 
treatment for them are fully described in the chapter on this 
disease. So also are the use of salt solution and stimulants in 
serious cases of diarrheal disease. 

INTESTINAL TOXEMIA OF THE NEW-BORN 

This condition, although not a very uncommon one, is often 
overlooked or mistaken for some other disease. Being in all 
probability due to bacterial infection of the retained meconium and 
the absorption of the toxic products formed by them in the meco- 
nium, it seems more rational to consider it under the head of indi- 
gestion with fermentation than elsewhere. There are no data as to 
the nature of the causative organisms or the pathological changes. 
The clinical picture is as follows: 



INTESTINAL TOXEMIA OF NEW-BORN 299 

Symptomatology. — A baby that was normal at birth and has 
continued to seem normal and to do well up to the second, third, 
fourth or even fifth day, becomes rather suddenly ill. He is likely 
to cry and moan considerably, although he is not infrequently 
unusually quiet. Attacks of cyanosis are a common and early 
symptom. Twitching of the extremities, slight general rigidity 
and retraction of the head come on in many instances, while con- 
vulsions are not infrequent. The temperature is, as a rule, only 
moderately raised, but may be high. In the more severe cases the 
baby refuses to nurse. Vomiting is uncommon. In most instances 
there is no diarrhea; in fact, the tendency is to constipation. The 
symptoms develop in the majority of instances before the baby has 
ceased to pass meconium and it is very common to find that it has 
not passed as much as the average baby. If the stools are not 
composed of meconium, they are usually small in amount, loose, 
dark-brown and contain small, soft curds and mucus. They are 
often offensive. The abdomen may be distended, but usually is 
not. Loss of weight is generally rapid, the face becomes pinched 
and in all but the mildest cases it is evident that the baby is 
seriously ill. If the bowels are throughly cleaned out, all food 
stopped for a time and water given freely, recovery is usually rapid 
and complete. If the bowels are not cleaned out and food is 
continued, a fatal termination is not uncommon and recovery is, in 
any event, slow. 

Etiology. — The most reasonable explanation as to the etiology of 
these cases is that a bacterial infection of the meconium, through 
either the mouth or anus, takes place within the first twenty-four 
or forty-eight hours after birth; that on account of the incomplete 
evacuation of the intestines the toxic products formed in the 
meconium as the result of this infection are absorbed into the cir- 
culation and that these toxic products cause the symptoms. 
Corroborative evidence in favor of this conception is that, as the 
meconium is made up of protein, the products of bacterial action in 
it must necessarily be putrefactive in character and, therefore, 
toxic. It is a well-known fact, moreover, that cyanosis may be 
enterogenous in origin. It may be asked why this symptom- 
complex is not merely a manifestation of septic infection, that is, 
of the entrance of bacteria into the circulation. It is impossible to 
state positively that this is not the case, because no blood cultures 
have been made in these patients. The early onset of the symp- 
toms, the absence of any nidus of infection and the absence of 
other signs of sepsis, such as hemorrhages, marked jaundice and 
boils, make it improbable, while the rapid and complete recovery 



300 INDIGESTION WITH FERMENTATION 

after the evacuation of the bowels seems sufficient to exclude it. 
It may also be asked why it is not simply a manifestation of starva- 
tion, analogous to the so-called " inanition fever." The answer is 
that it occurs both in babies that have not been fed and in those 
that have been, and that the withdrawal of food in connection 
with the evacuation of the bowels relieves it. 

Diagnosis. — The diseases for which this condition is most 
likely to be mistaken are cerebral hemorrhage as the result of 
injury at birth, meningitis, hemorrhagic disease of the new-born 
and septic infection of the new-born. The diagnosis from septic 
infection of the new-born is the most difficult. The symptoms ap- 
pear earlier, as a rule, than do those of septic infection and the 
temperature is usually lower than in sepsis. There is no local 
nidus of infection, and marked general and local symptoms of 
infection, such as hemorrhages, deep jaundice and furuncles, are 
absent. There is a tendency to constipation and the stools are 
usually meconium-like in character. In many instances it is, 
however, impossible to make a positive diagnosis without the 
therapeutic test of free catharsis. Hemorrhagic disease of the 
new-boin can be excluded on the absence of hemorrhages. Men- 
ingitis is extremely rare at this age and, when it occurs, it is a 
part of a general septic infection. There is almost invariably 
bulging of the anterior fontanelle in meningitis and usually when 
there is a cerebral hemorrhage. There are usually symptoms of 
focal irritation in hemorrhage and often blood in the nose and 
nasopharynx, while in both cerebral hemorrhage and meningitis 
there is likely to be spasm of the extremities and exaggeration of the 
knee-jerks. These latter symptoms, as well as other symptoms of 
cerebral irritation, may, however, also be present in intestinal 
toxemia. A lumbar puncture will settle the diagnosis at once in a 
doubtful case. 

Prognosis. — The prognosis is a grave one in all but the mild 
cases, unless the condition is properly treated. If the bowels are 
throughly cleaned out at once and food stopped for a time, re- 
covery is usually rapid. 

Treatment. — The treatment consists in the administration of one 
or two teaspoonfuls of castor oil, the withdrawal of food for from 
twelve to twenty-four hours and the feeding of water or water 
sweetened with saccharin. It is also well to irrigate the bowels in 
the beginning. Bromide or stimulants, such as strychnia or 
caffein, may be used, if necessary. The best food, after the period 
of starvation, is human milk, plain or diluted, according to the 
individual baby's condition. Next to this, a mixture of cow's milk, 



INDIGESTION WITH FERMENTATION 301 

low in fat, high in milk sugar and with a moderate amount of 
proteins, part of these preferably in the form of the whey proteins. 
A mixture containing 0.50% of fat, 5% of milk sugar, 0.50% of 
whey protein and 0.25% of casein would be a suitable one. It is 
important to give a high percentage of milk sugar in order to 
change the bacterial activity from the proteolytic to the fermenta- 
tive type. 



CHAPTER XXV 
INFECTIOUS DIARRHEA 

The border line between indigestion with fermentation and 
infectious diarrhea is necessarily a very indefinite one. The 
symptoms in severe cases of indigestion with fermentation differ 
but little from those in mild cases of infectious diarrhea. In both 
instances toxic substances, resulting from bacterial growth, are 
absorbed into the circulation and cause similar symptoms and 
pathological changes. In indigestion with fermentation, however, 
the bacteria do not enter the intestinal wall. The local lesions are, 
therefore, relatively insignificant. In infectious diarrhea, on the 
other hand, the bacteria do enter the intestinal wall and produce 
definite lesions of the wall. These lesions may or may not be 
severe. It is probable that bacteria very seldom pass through the 
intestinal wall and enter the circulation in indigestion with fer- 
mentation. It is probable that they often pass through the wall 
into the circulation in infectious diarrhea. In indigestion with 
fermentation the seat of bacterial activity is primarily and almost 
exclusively in the intestinal contents, while in infectious diarrhea 
it is primarily in the intestinal wall itself. In indigestion with 
fermentation bacteria are the secondary invaders of an abnormal 
intestinal content, while in infectious diarrhea they are the primary 
cause of the disease. These distinctions must not, however, be 
regarded as absolute. They are, nevertheless, definite enough to 
serve as a basis for classification and for treatment. 

Etiology. — Infectious diarrhea is more common in hot weather 
than at other times of the year. The action of heat in the produc- 
tion of the disease is due mainly to the lowering of the general 
resistance to infection which it produces. It presumably also 
favors the development outside of the body of the microorganisms 
which are found in this disease. Microorganisms are, however, the 
primary cause of infectious diarrhea. The microorganisms which 
produce this disease are of several different types. They may be 
divided roughly into three main classes: 

a. The dysentery bacillus in all its forms. 

b. The gas bacillus and similar organisms. 

c. Other organisms, of which the most important are strepto- 

cocci, the colon bacillus and the bacillus pyocyaneus. 

302 



PATHOLOGY 303 

The symptoms produced by these different types of organisms 
are practically identical. It is usually impossible to determine 
from them which type of organism is causing the disturbance. 

Several investigators have recently claimed that the gas bacillus 
is never the cause of infectious diarrhea. 1 Their results do not 
seem conclusive enough, however, to overthrow the work of Kend- 
all and his associates. 2 Furthermore the results of treatment based 
on a varied etiology seem sufficient to prove that all cases are not 
due to the dysentery bacillus. 

Pathology. — The pathological lesions of the intestine are very 
varied. There may be only a catarrhal inflammation. In other 
cases there are also superficial ulcerations. In others there is hy- 
perplasia of the solitary follicles and Peyer's patches. In many 
instances ulceration takes the place of the hyperplasia of these 
structures. In still others a pseudo-membrane is formed, which 
may involve considerable areas. The pathological lesions are usu- 
ally limited to the large intestine and the last two or three feet of 
the small intestine. They are ordinarily most marked in the large 
intestine. The severity of the symptoms does not always coincide 
with the severity of the intestinal lesions. In general, however, the 
symptoms are most marked in the cases in which the lesions are 
the most serious. 

There is almost invariably a hyperplasia of the mesenteric 
lymph nodes. This almost never, however, goes on to suppuration. 
There are always more or less marked degenerative changes in the 
parenchymatous organs, especially in the liver and kidneys. True 
inflammation of the kidneys is, however, uncommon. Secondary 
infections of other organs, such as the middle ears and lungs, by 
other organisms as the result of the general weakened resistance, 
are not infrequent. 

Symptomatology. — The onset of infectious diarrhea is usually 
acute. It may be preceded for a few days by symptoms of indiges- 
tion, but ordinarily there are no premonitory symptoms. The 
first symptom in most cases is diarrhea. The first stools are made 
up of fecal matter. Mucus and blood soon appear, however, and 
after a few hours or a day or two, the stools are composed almost 
entirely of mucus and blood. Pus is seldom visible macroscop- 
ically until several days after the onset and, in many instances, it 

1 Knox and Ford: Bull. Johns Hopkins Hosp., 1915, xxvi, 27; Ten Broeck 
and Norbury: Boston Med. and Surg. Journ., 1915, clxxiii, 280 and 1916, 
clxxiv, 785. 

2 Kendall: Boston Med. and Surg. Journ., 1915, clxxii, 851; Sylvester 
and Hibben: Archives of Pediatrics, 1915, xxxii, 457. 



304 SYMPTOMATOLOGY 

is never seen. It can, however, almost alwaj^s be found with the 
microscope. Membrance is also present in the severest cases. 
The mucus is often stained green or brown. The odor of the stools, 
when they are made up chiefly of mucus and blood, is very slight, 
but sometimes resembles that of wet hay. When the stools con- 
tain much pus or membrance, as the result of deep ulcerative or 
gangrenous processes in the intestine, the odor is putrefactive or 
gangrenous. The reaction of the stools is variable, but in most 
instances it is somewhat alkaline. The number of stools is large, 
twelve, twenty-four, or even more, in twenty-four hours. The 
stools are usually small, being often merely a stain of blood and 
mucus. In a general way, the larger the number of stools, the 
smaller are the individual stools. 

Pain in the abdomen and tenesmus are early, marked and severe 
symptoms. Tenesmus is especially troublesome and annoying and 
often keeps the baby restless and disturbed and prevents it from 
getting the proper amount of sleep. Prolapse of the rectum is not 
at all infrequent as the result of the straining. 

Vomiting is a rather infrequent symptom and is seldom trouble- 
some. The appetite is usually much impaired and there is not 
infrequently the greatest distaste for food of any sort. 

The abdomen is sometimes distended, but in the vast majority 
of instances is much sunken. There is almost never any spasm of 
the abdominal muscles. There is sometimes tenderness over the 
course of the colon, but this is unusual. There is usually no en- 
largement of either the liver or of the spleen. Slight enlargement 
of the spleen is, however, not very uncommon. In some instances 
the liver becomes very large and this enlargement may develop 
very rapidly. The liver will sometimes enlarge enough in three or 
four days to reach well below the navel and to the anterior superior 
spine. 

The temperature is always elevated in infectious diarrhea. It is 
usually only moderate, 100° F. to 102° F., but may be several de- 
grees higher. It is more likely to be high in the beginning than 
later. The temperature is usually a fairly constant one without 
marked intermissions or remissions. It lasts throughout the active 
stage of the disease. 

The symptoms are, however, not always so characteristic. The 
number of stools may be but little increased, mucus and blood may 
be scanty, or even wanting, and tenesmus absent. The symptoms 
may be, in fact, precisely like those of severe simple indigestion 
or of indigestion with fermentation. In such instances the con- 
tinued temperature is the most suggestive symptom. The real 



SYMPTOMATOLOGY 305 

condition can only be recognized in such instances, however, by a 
bacteriological examination of the stools. 

The blood almost always shows a moderate, polynuclear leuco- 
cytosis, usually somewhere in the neighborhood of 20,000. It may 
however, be much higher. In the severest cases in which the toxe- 
mia is extreme and the system is unable to react, there may be no 
leucocytosis or even a leucopenia. 

The urine is almost invariably diminished as the result of the 
loss of fluid through the bowels and the diminution in the intake. 
It not infrequently shows the evidences of acute degeneration of 
the kidneys. Acute inflammation of the kidneys is very unusual. 
The urine rarely contains sugar unless the toxemia is extreme or 
very large amounts of sugar are being ingested. 

In the most severe and fatal cases, certain symptoms, such as 
uncontrollable vomiting, marked prostration and hyperpyrexia, 
presumably due largely to toxic absorption, develop. These symp- 
toms may also develop in the course of indigestion with fermen- 
tation. They will be discussed more in detail later and the treat- 
ment for them described at the same time. 

It is impossible to determine from the symptoms what form of 
organism is the cause of the disease in the individual case. There is 
nothing about the stools which will aid in the differentiation except, 
in rare instances, the peculiar green color caused by the bacillus 
pyocyaneus. If the green color is produced by this organism, it 
will disappear when nitric acid is added to the stool. If it is due to 
bile, the characteristic color of Gmelin's test will appear when 
nitric acid is added. The microscopic examination of the stools is 
of little assistance in differentiating the various types unless the 
streptococcus is the cause, in which case it is usually present in 
large numbers and easily recognized. The presence or absence of 
the gas bacillus can be determined in from eighteen hours to 
twenty-four hours, or even less, by the following method : 

This method is a simple one, which can be easily carried out by 
anyone. A small portion of the stool is added to a test tube of 
milk. The infected tube is then gradually brought to the boiling 
point of water in a water-bath and kept there for three minutes. 
In this way, all the bacteria not in the spore state are killed and the 
development of whatever spores may be present into vegetative 
cells is unrestrained by the presence of non-spore-forming organ- 
isms. The tube is then incubated at body temperature for from 
eighteen to twenty-four hours. When the gas bacillus is present, 
the casein is largely dissolved (usually at least 80%); the resid- 
ual casein is somewhat pinkish in color and filled with holes; and 



306 TEST FOR GAS BACILLUS 

the odor of the culture is much like that of rancid butter, as the 
result of the formation of butyric acid by the gas bacillus. Gram 
stained preparations made from the milk show rather thick, short, 
Gram-positive bacilli, with slightly rounded ends. The fermenta- 
tion is more easily observed if the milk, after being boiled, is put 
in a sterile fermentation tube. " Pseudo-reactions' ' may occur 
in which there is some liquefaction of the casein, but the shotted 
appearance of the residual casein is absent and there is no odor of 
butyric acid. 1 The following method is also simple and satisfac- 
tory: Fill a fermentation tube and large test tube with concen- 
trated nitric acid. Pour off acid after three minutes and rinse with 
hot tap water until neutral to litmus. With a glass spatula, also 
soaked in acid and washed until neutral, place about one c. c. of dex- 
tri-maltose and one c. c. of stool in one-third test tube of water. 
Boil vigorously one-half minute and pour into fermentation tube, 
tilting back and forth to eliminate bubbles. Stopper tube with 
flamed cotton and place in incubator at 37° C. for twenty-four 
hours. Then inspect tube for gas and note amount. If no gas is 
formed or the bubble is no larger than a pinhead, the result is nega- 
tive. If there is less than one-half inch of gas, the result is ques- 
tionable. If there is one-half inch or more of gas, the result is posi- 
tive. 2 It must be remembered, however, in interpreting the 
results of this test, that the presence of a few gas bacilli does not 
necessarily prove that they are the cause of the disease. There is, 
unfortunately, no method for determining the presence or absence 
of dysentary bacilli that does not require special media and a fairly 
well equipped laboratory. Baker 3 has, however, recently de- 
veloped an intracutaneous test for the dysentery bacillus which 
gives positive results in from six to eighteen hours and which, 
promises to be most useful. 

Diagnosis. — The only disease with which a typical case of in- 
fectious diarrhea is likely to be confused is intussusception. It is, 
however, usually not difficult to differentiate between these two 
conditions. Intussusception begins acutely with pain in the ab- 
domen and evidences of shock, the stools of mucus and blood not 
appearing until later. The onset of infectious diarrhea is less acute, 
pain is usually not present, or, if so, it is slight, and there are no 
symptoms of shock, while the stools of mucus and blood appear 
almost at once. The stools contain no fecal matter in intussuscep- 

1 See Kendall and Smith: Boston Medical and Surgical Journal, 1910, 
Vol. clxiii, 578. 

2 Sylvester and Hibben: Archives of Pediatrics, 1915, xxxii, 457. 

3 Baker: Journal of Immunology, 1917, ii, 453. 



DIAGNOSIS 307 

tion, while they usually contain some in infectious diarrhea. Fever 
is common to both diseases, but is usually higher in infectious di- 
arrhea than in intussusception. The abdomen is almost always 
sunken in infectious diarrhea, but likely to be somewhat distended 
in intussusception. There is never any muscular spasm in infec- 
tious diarrhea, usually some in intussusception. There may be 
abdominal tenderness in both conditions. It is seldom marked in 
either, however, and is not of importance in the differential diagno- 
sis. There is never a tumor in the abdomen or rectum in infectious 
diarrhea, while there often is one in intussusception. The absence 
of a tumor does not, however, rule out intussusception. Both con- 
ditions are usually, but not always, accompanied by a leucocy- 
tosis. 

Simple indigestion and indigestion with fermentation are not 
likely to be mistaken for infectious diarrhea. Mild cases of in- 
fectious diarrhea in which the number of stools is not very large 
and in which there is no blood and relatively little mucus in the 
stools are very likely, on the other hand, to be mistaken for in- 
digestion with fermentation. Fever, abdominal discomfort, ano- 
rexia, wasting and symptoms of toxic absorption are common to 
both conditions. These symptoms differ only in degree in the 
two diseases and may be more marked in indigestion with fermen- 
tation than in mild cases of infectious diarrhea. It is often very 
difficult to differentiate between them and it is not infrequently 
impossible to make a positive diagnosis. The most important 
single symptom in the diagnosis is probably the temperature curve, 
the elevation of temperature in digestion with fermentation being 
ordinarily either very slight or high and of short duration, while 
in infectious diarrhea, although usually not very high, it is con- 
stant and continuous. In many instances a positive diagnosis can 
only be made by a bacteriological examination of the stools. An 
agglutination reaction is usually present in infectious diarrhea by 
the end of the first week or a little later when the disease is caused 
by the bacillus of dysentery. This reaction is, however, of but 
little practical importance. 

When the temperature is high and the symptoms of cerebral 
irritation are marked and develop before the appearance of the 
characteristic stools, as they sometimes do, the disease may be 
mistaken for some form of meningitis. A careful analysis of the 
symptoms and physical signs will, however, usually make the 
diagnosis plain. A lumbar puncture will settle it at once. 

Prognosis. — Infectious diarrhea in infancy is always a serious 
disease. The prognosis should always be a guarded one. It is 



308 TREATMENT 

impossible to know in the beginning what the result is to be. 
Death may occur in three or four days, but most often takes place 
during the second week of the disease. It may be delayed, how- 
ever, for several weeks. Improvement usually begins, in the cases 
which recover, at the end of the first or during the second week. 
It may be delayed for several weeks. Recovery is usually slow 
and likely to be interrupted by relapses. In some instances the 
disease runs into a chronic form which may last for many weeks. 
Most of these cases eventually die, but some recover. 

Symptoms which render the prognosis more serious are high 
fever, the presence of much blood in the stools and the appearance 
of symptoms of marked toxic absorption, such as persistent vomit- 
ing, marked restlessness and convulsions. The presence of albumin 
and other evidences of degeneration of the kidney in the urine are 
not of especially bad prognostic import. 

Treatment. — The first thing to be done in infectious diarrhea is 
to thoroughly clean out the intestinal tract. The best drug for this 
purpose is castor oil. It works quickly, thoroughly and causes less 
irritation of the intestines than other cathartics. The dose should 
not be less than two teaspoonfuls and may be as much as two 
tablespoonfuls. It should be given plain. Castor oil should be 
tried first, even if the baby is vomiting, because it is often retained 
when food and water are vomited. If it is vomited, calomel may 
be given in its place. The usual dose is one-tenth of a grain, com- 
bined with one grain of bicarbonate of soda, every half hour until 
1 or 1}4 grains have been given. It is wise to follow it with two 
or three teaspoonfuls of the milk of magnesia in two or three hours 
after the last dose. The treatment should be repeated, if the 
desired results are not obtained. The lower bowel should also 
be irrigated at once with physiological salt solution (approximately 
one teaspoonful of salt to a pint of water). 

All food should be stopped for from twelve to twenty-four 
hours. It is not desirable, as a rule, to withhold food longer than 
this. It is necessary, however, to give water freely during this 
period, because, although a baby can bear temporary starvation, it 
cannot get along without water. At least as much water should be 
given as the baby would normally take of liquid in the form of 
food in the given time. The water may be given either warm or 
cool and may be sweetened with saccharin, if desired. There is no 
objection to giving it in the form of weak tea sweetened with 
saccharin, if it is taken better in this way. It should be given 
through a tube, if the baby will not take it otherwise. 

The most important element in the treatment of infectious 



TREATMENT 309 

diarrhea is the diet. The character of the diet depends on the 
variety of microorganism which is causing the disease. These 
microorganisms can be divided, as far as the determination of the 
diet to be used in concerned, into two groups; 

1. The various forms of the dysentery bacillus and the other 
organisms, except the gas bacillus, which cause the disease. 

2. The gas bacillus and allied organisms. 

The other organisms, although of many different varieties, are 
grouped with the dysentery bacilli, because as regards their growth 
and the production of toxic substances from protein and carbo- 
hydrate media, they behave in the same way. 

The dysentery bacillus, the colon bacillus and the streptococcus 
belong to the class of facultative bacteria. This class of organisms 
can thrive upon either carbohydrate or protein media. They 
produce harmless products from carbohydrates and toxic sub- 
stances from protein. They act upon and use up the carbohydrate 
material before they attack the protein, when both are present in 
the medium in which they are growing. The products of the 
breaking down of the carbohydrate material have, moreover, when 
produced in sufficient amounts, an inhibitory action on the develop- 
ment of dysentery bacilli and, to a less extent, of streptococci. 

It is evident, therefore, that when infectious diarrhea is caused 
by bacteria of this type, the food should be largely carbohydrate in 
character. In this way the organisms are prevented from forming 
toxic substances and their growth is, to a certain extent, inhibited. 
The prolonged withdrawal of food is also contraindicated, because 
the intestinal contents are then made up entirely of the intestinal 
secretions, which are protein in character. Some form of carbo- 
hydrate should, therefore, be given after a few hours. Sugar is 
preferable to starch, because it is much more easily utilized by 
bacteria. Lactose is preferable to the dextrin-maltose preparations, 
because it is more slowly broken down during the processes of 
digestion. Being less readily absorbed, it thus provides a carbo- 
hydrate medium in the intestine for a longer time than the dextrin- 
maltose combinations. It is probable, moreover, that a larger 
proportion of lactic acid is formed from milk sugar than from 
the other sugars, and lactic acid has an inhibitory action on the 
development of the dysentery bacillus. The lactose should be 
given in the form of a 5% or 7% solution in water. It is better to 
give it frequently in small amounts than in larger amounts at 
longer intervals, because in this way a continuous supply of lactose 



310 TREATMENT 

is brought to the intestines. The baby should be given at least 
as much of the sugar solution as it would take of food under normal 
conditions. Half as much more is usually advisable. There is 
little or no danger of producing sugar indigestion or glycosuria, if 
no more than this is given. 

After twenty-four, forty-eight or seventy-two hours, as the case 
may be, it is wise to give the milk sugar in barley water. The 
barley water should contain from 0.75% to 1% of starch. The 
starch provides more nourishment and, being still more slowly 
broken up and absorbed, favors still further the prolonged con- 
tinuance of a carbohydrate medium in the intestine. 

It is necessary to add some protein to the food as soon as possible 
in order to neutralize the protein waste of the organism. It should 
be given as soon as there is evidence of improvement of the condi- 
tion. Care must be taken not to give so much as to neutralize the 
action of the carbohydrates. It is usually safe to begin with 
0.50%, increasing the amount 0.25% at a time as fast as possible 
up to about 1.50%. It may be given either in the form of whey 
protein or casein. If it is added in the form of casein, the mixture 
should be boiled in order to prevent the formation of casein curds. 
No fat should be given until convalescence is well established. 

Irrigations of the colon with solutions of lactose or dextrose, 
while theoretically indicated, are of little practical value. 

The microorganisms which cause the disease enter the intestinal 
wall and probably in many instances reach the mesenteric lymph 
nodes and perhaps the general circulation. The available supply 
of glycogen is quickly used up or greatly diminished in illness, 
especially when associated with total or partial starvation, and the 
conditions favorable for the development of toxic substances by 
the bacteria which have left the intestines are thus provided. The 
introduction of dextrose into the circulation would, therefore, 
furnish a carbohydrate instead of a protein medium for the bacteria 
to grow in. The dextrose also provides an immediately utilizable 
supply of energy and spares the body protein. Dextrose infusions 
are, therefore, indicated in severe cases of infectious diarrhea of 
this type and in cases which are not yielding rapidly to treatment. 
The strength of the infusion should be 2.5% of dextrose in normal 
saline solution. Kahlbaum's is the only readily available pure 
dextrose. Three or four ounces of the solution may be' given at a 
time and repeated every four to six hours. The administration of 
these infusions should be checked by urinalysis and must cease if 
sugar appears in the urine. 

The gas bacillus and allied organisms grow rapidly in the in- 



TREATMENT 311 

testinal tract when there is an excess of utilizable carbohydrate in 
the bowel and at the same time an insufficient number of those 
organisms which form lactic acid from carbohydrates to produce 
enough lactic acid to inhibit their gorwth, the gas bacillus being 
sensitive to lactic acid. The indications to be followed in the treat- 
ment of cases of infectious diarrhea caused by the gas bacillus are, 
therefore, to cut down the carbohydrates in the diet and to intro- 
duce acid producing bacteria into the intestines. These indica- 
tions can be best met by the use of unheated buttermilk or, better, 
of mixtures containing no fat, 3% or 4% of milk sugar and from 
1.50% to 2.50% of protein, ripened with lactic acid forming or- 
ganisms. It is not impossible to cut out the sugar entirely, be- 
cause, if this is done, the lactic acid forming organisms will have 
nothing on which to grow. The lactic acid already present in the 
food exerts an immediately inhibitory action upon the gas bacillus, 
while the lactic acid forming organisms in it, by keeping up their 
production of lactic acid, continue this action. They also use up the 
available supply of carbohydrate and thus interfere with the 
growth of the gas bacillus. Lactic acid given by the mouth is much 
less effective, because it is rapidly broken down and absorbed and, 
therefore, does not have a continuous action. Pasteurized butter- 
milk, in which the lactic acid forming organisms are destroyed, is 
less valuable than raw buttermilk for the same reason. 

Cutting down the carbohydrates in the diet and increasing the 
amount of protein in it is sufficient to relieve the condition in mild 
cases. The percentage of fat should also be kept low. Mixtures 
containing from 1% to 1.50% of fat and from 1.50% to 3% of pro- 
tein, and with no more milk sugar than is necessarily added in the 
milk and cream to give the desired percentages of fat and protein 
are suitable ones. It is well to boil them in order to prevent the 
formation of casein curds. 

It is evident that the line of diet which is suitable for one type of 
infectious diarrhea is not only not suitable, but absolutely harmful, 
for the other, and vice versa. It is extremely important, therefore, 
not to make a mistake in the choice. It is unfortunately almost 
impossible to determine at once what form of microorganism is the 
cause in the individual case. The various methods to be used to 
get at the organism at fault have already been detailed. A point 
which is of some assistance in arriving at a tentative conclusion 
until these measures have been carried out is that in a given season 
the vast majority of the cases of infectious diarrhea are due to the 
same organism. If the prevailing organism is known, the chances 
are, therefore, that this organism is also the cause in the given case. 



312 TREATMENT 

Another method of determining the cause, a method which is 
most unscientific but nevertheless often the only practicable one, 
is to give what seems to be the most rational diet and then observe 
the results. If the temperature begins to come down and the pa- 
tient improves, it is almost certain that the organism causing the 
disease is of the type for which that form of dietetic treatment is 
indicated. If, on the other hand, the temperature remains ele- 
vated or rises and there is no improvement in the other symptoms, 
it is evident that the causative organism belongs to the other type 
and that the diet must be changed. 

Irrigation of the bowels once or twice in the twenty-four hours is 
a useful procedure. The object of the irrigation is simply to 
cleanse the colon. It is impossible to use astringent solutions 
strong enough to have any appreciable action upon the intestinal 
wall, even if this was desirable, or antiseptic solutions strong 
enough to have any effect upon the pathogenic bacteria without 
running serious risk of poisoning the baby. The irrigating solution 
should, therefore, be some mild, unirritating solution, such as 
physiological salt solution or a 1% solution of boracic acid. The 
irrigation should be given with a soft rubber catheter, No. 25 
French, passed as high as possible into the bowel, with the patient 
lying on the back and the hips elevated. The fluid is then allowed 
to run in from a bag hung not more than two feet above the level 
of the patient. It should be allowed to run in until the abdomen 
is slightly distended, then allowed to run out, and so on, until the 
wash water returns clear. The object of the irrigation being to 
cleanse the colon, enough liquid should be used to do this, whether 
it is much or little. Irrigation should seldom be done more than 
twice in the twenty-four hours. If it depresses or disturbs the 
patient materially, it should be given up, as under these circum- 
stances it does more harm than good. 

In subacute or chronic cases, in which blood and pus persist in 
the stools after the temperature has dropped and the evidences 
of toxemia have disappeared, injections of nitrate of silver are 
sometimes useful and seem to hasten the healing of the bowel. 
They may be used in the acute stage, but, as a rule, do but little 
good at this time. The colon should first be irrigated with sterile 
water in order to cleanse it. Salt solution should not be used, be 
cause the sodium chloride forms with the silver nitrate an in- 
soluble silver salt which is precipitated and the action of the silver 
solution is consequently diminished. After the bowel has been 
washed out, from six to sixteen ounces, according to the age of the 
baby, of a 2% or 3% solution of the nitrate of silver are allowed to 



TREATMENT 313 

run into the colon and the tube then withdrawn. No attempt 
should be made to have the fluid either retained or expelled. This 
procedure seldom causes any marked discomfort in babies. If it 
does, the silver solution may be washed out with salt solution or an 
opium suppository given. The injections should be repeated every 
day or every other day. If there is no evident improvement after 
three or four injections it is useless to continue them. The first 
stools passed after an injection usually contain more blood and 
considerable dirty gray material, consisting of slough from the 
ulcers, intestinal secretions and pus, discolored by the silver ni- 
trate. In favorable cases, however, there is marked improvement 
in the character of the stools inside of twenty-four hours. 

The various so-called intestinal antiseptics are of little or no 
value in the treatment of infectious diarrhea. It is impossible to 
give them in large enough doses to have any effect on the path- 
ogenic bacteria in the intestines without poisoning the baby. If 
they did have any action, it would be exerted on the antagonistic 
as well as on the pathogenic bacteria. Moreover, the bacterial 
flora can be modified better by regulation of the diet than in any 
other way. In addition, it disturbs the patient to take them and 
interferes with the administration of food and water. The salts of 
bismuth are of little value during the acute stage, whether or not 
they are combined with sulphur. During the chronic stage they 
sometimes seem to diminish peristalsis and perhaps promote heal- 
ing. When used, they should be given in doses of from ten to 
twenty grains every two hours. It is safer to use the subcarbonate 
or the milk of bismuth than the subnitrate, because of the danger 
of nitrite poisoning when the subnitrate is used. 

There is no serum which is of any value in the treatment of 
infectious diarrhea. 

Pain and tenesmus are often very troublesome symptoms. In- 
jections of two ounces of starch solution of the strength of one 
drachm of starch to one ounce of water, to which are added from 
three to five drops of laudanum, will sometimes control the tenes- 
mus. They are usually expelled, however, before they have had 
time to do any good. It is generally wiser, therefore, to give the 
opium by mouth, if it is necessary to use it at all. It must be 
remembered when giving opium that its action is to diminish 
peristalsis and that if the peristalsis is diminished enough to inter- 
fere with the free emptying of the bowels serious harm will be done. 
Only enough should be given to allay the tenesmus and prevent 
the frequent stools due to excessive peristalsis. The safest form of 
opium to use is paregoric. It may be given in doses of from five to 



3U TREATMENT 

twenty drops. Dover's powder, in doses of from one-eighth to one- 
half of a grain, may also be used. It is better to give small doses 
at short intervals than larger doses at longer intervals. The use of 
hot stupes or compresses to the abdomen will, however, often 
relieve the pain and tenesmus and render the use of opium un- 
necessary. 

In some instances it is impossible to induce the infant to take a 
sufficient amount of water or, if it does take it or it is given through 
a tube, it is vomited. In such cases physiological salt solution 
should be given subcutaneously to make up the deficit. From four 
to six ounces may be given at a time and repeated as often as nec- 
essary. It is useless to give a second injection, however, before 
the first one is absorbed. Salt solution may also be given through 
the bowel by seepage. Considerable amounts can sometimes be 
introduced in this way, even when the baby is having many stools. 
It may also be given into the longitudinal sinus or intraperitoneally. 

Stimulants are often necessary in infectious diarrhea in infancy, 
as in other acute diseases. There are no special rules to be followed 
in infectious diarrhea. Alcohol is of doubtful value. Strychnia is, 
in general, the most useful, while caffeine and camphor are the 
best quick stimulants. Strychnia may be given in doses of from 
1/1000 to 1/200 of a grain. The dose of the citrate of caffeine by 
mouth for a baby is from one-eighth to one-half of a grain and of 
caffeine-sodium benzoate or salicylate subcutaneously about the 
same. Camphor may be given subcutaneously in oil in doses of 
one or two grains. 

Special Symptoms. — Babies that are seriously ill with either 
indigestion with fermentation or infectious diarrhea are very likely 
to show one or more rather characteristic symptoms or groups of 
symptoms. One of these groups of symptoms almost invariably 
develops toward the end in fatal cases. These symptoms are: 

a. Excessive vomiting. 

b. Hyperpyrexia. 

c. Symptoms of irritation of the central nervous system. 

d. Prostration and collapse. 

It is probable that these symptoms are chiefly manifestations of 
toxemia. How much of the intoxication is due to the absorption 
of bacterial endotoxines and extracellular toxines, how much to the 
absorption of the products of bacterial fermentation in the intes- 
tinal contents, and how much to purely chemical disturbances of 
metabolism, it is impossible to state. It is presumable that the 



VOMITING AND HYPERPYREXIA 315 

loss of water through the bowels also plays a part in their produc- 
tion. 

If, when any of these symptoms appear, there is any doubt as to 
whether the bowels have been throughly emptied, it is advisable 
to repeat the initial catharsis and irrigation. It is also advisable, if 
the condition of the nutrition warrants it, to withhold food for 
about twelve hours. This must be done only after due deliberation, 
however, if the cause of the infectious diarrhea is any other or- 
ganism than the gas bacillus. In all of these cases, unless the 
babies are taking and retaining sufficient liquid by mouth, it is 
advisable to give salt solution subcutaneously or by seepage. 

Little can be done for excessive vomiting beyond the general 
measures already detailed, except to withdraw all food entirely and 
wash out the stomach with a solution of bicarbonate of soda of the 
strength of one level teaspoonful to the pint of water. In some 
instances, small amounts of this same solution of bicarbonate of 
soda, of one of the aerated waters or of ginger ale, will be retained 
when food and water are not. The vomitus not infrequently con- 
tains brownish or reddish flecks or streaks as the result of capillary 
hemorrhages into the stomach. This sign is of serious, but not 
necessarily of fatal, import. 

The hyperpyrexia is best treated by the use of cold externally. 
It is very seldom advisable to give the coal tar products to infants 
to reduce the temperature. Sponge baths of equal parts of alcohol 
and water, at 90° F., are usually effective. If they are not, fan 
baths may be tried. Fan baths are given in the following way: 
The baby is stripped and wrapped in cheesecloth. This is then 
wet with water at 100° F. and the baby is fanned. The tempera- 
ture is reduced by the evaporation of the water. The cheesecloth 
is wet from time to time as the water evaporates. Babies seldom 
object to this form of bath. If this is ineffectual, the cold pack at 
from 60° F. to 70° F. should be tried. Babies seldom bear tub 
baths well and it is, as a rule, wiser not to use them. 

An ice bag may also be applied to the head. It must not be 
forgotten, however, that a baby's skull is very thin and that the 
effect of the cold is, therefore, greater than in the adult. This is 
especially true when the fontanelle is open. Great care must, 
therefore, be exercised in the use of the ice cap in infancy. 

Lowering the temperature of the liquid used in irrigating also 
aids in reducing the fever. It may be reduced to 100° F. or 95° F. 
and in desperate cases to 90° F. 

The nervous symptoms are very varied. In some instances the 
babies are stupid, comatose or relaxed. In others they show the 



316 NERVOUS SYMPTOMS 

typical picture of coma vigil. Marked restlessness is a very com- 
mon manifestation. Twitching is not uncommon and convulsions 
not very infrequent. In many instances there are marked signs of 
meningeal irritation. The head may be retracted, the pupils 
unequal, the knee-jerks exaggerated, and so on. In fact, the 
picture may be almost exactly that of meningitis, so much so that a 
diagnosis can only be made positively by lumbar puncture. The 
results of this procedure are also sometimes misleading, because the 
cerebrospinal fluid in this condition sometimes shows a slight 
globulin test and a moderate excess of mononuclear cells. The 
pathological condition is presumably one of meningeal irritation or 
serous meningitis. The treatment of these nervous manifestations 
is purely symptomatic. Bromide of soda, in doses of from five to 
ten grains, by mouth, may be given for restlessness and excite- 
ment. It may be combined with one or two grains of chloral 
hydrate. It is ordinarily useless to give drugs by enema in these 
conditions, as they are almost never retained. If the bromide and 
chloral do not control the symptoms, morphine may be given by 
mouth or subcutaneously, in doses of from 1/100 of a grain to 1/32 
of a grain. It is always advisable in giving morphine to infants to 
begin with a very small dose and then increase it, if necessary. 
An ice bag on the head sometimes helps. When the fontanelle is 
full, a lumbar puncture will often give relief . Convulsions should 
be treated in the usual manner. 

There is nothing especially characteristic about the manifesta- 
tions of prostration and collapse in these conditions. They are to 
be treated in the same way that they are when they occur in other 
conditions. It is important to remember, however, that all forms 
of treatment weaken and exhaust the baby. Irrigations must be 
omitted and the baby disturbed as little as possible. It must be 
kept warm and protected in every way. They are likely, however, 
to be associated with a certain amount of vasomotor paralysis and 
lowering of the blood pressure. Alcohol is, therefore, contrain- 
dicated. Adrenalin is of some value under these circumstances, in 
doses of from two to ten minims of the 1-1000 solution, given 
subcutaneously. Its action is much greater when it is given in- 
travenously. Unfortunately, intravenous injection is not an easy 
matter in infancy. It has practically no effect when given by the 
stomach. Strychnia is, in general, the most useful of the stimu- 
lants, while caffeine and camphor are the best quick stimulants. 
Strychnia may be given in doses of from 1/1000 to 1/200 of a grain. 
The dose of the citrate of caffeine by mouth for a baby is from 
one-eighth to one-half a grain, and of caffeine-sodium benzoate or 



CHOLERA INFANTUM 317 

salicylate subcutaneously about the same. Camphor may be given 
subcutaneously in oil in doses of from one to two grains. 

CHOLERA INFANTUM 

There can be no doubt as to the existence of the symptom- 
complex which is usually designated by the name " cholera in- 
fantum. " It has all the earmarks of an acute, specific, infectious 
disease. Hence it seems rational to classify it under the head of 
infectious diarrhea. No specific microorganism has, however, ever 
been found for the disease. In fact, it is not certain that it is 
caused by any form or forms of microorganisms. It is possible 
that it is merely a peculiar manifestation of some unusual type of 
intoxication or disturbance of metabolism. However that may be, 
the symptom-complex is so striking that it deserves description as a 
separate entity. It is a rare condition. It almost never occurs in 
children over two years of age and never except in hot weather. 

Pathology. — The pathological changes are practically nil. All 
the tissues are drained of their liquid. There are no lesions of the 
intestines beyond the evidences of a desquamative catarrh or a 
moderate hyperemia of the mucous membrane. There may be 
evidences of cerebral hyperemia and occasionally of edema, but 
these are usually wanting. The kidneys show evidences of degen- 
eration, but no changes sufficient to account for the symptoms. 
The other parenchymatous organs also show degenerative changes. 

Symptomatology. — The symptoms are due primarily to the 
action of some toxic substance upon the heart and nervous system, 
the vasomotor nerves of the intestines being especially affected, 
and secondarily, to the draining of fluid from the various organs. 

The onset of the disease is usually preceded by some of the 
symptoms of indigestion, but it may develop in an infant ap- 
parently perfectly healthy. The development of the symptoms 
when they once appear is, however, extremely rapid, so rapid, in 
fact, that a baby may be moribund in five or six hours. The first 
symptoms are ordinarily restlessness or prostration with more or 
less abdominal discomfort and a rising temperature. Vomiting 
begins in a few hours and is accompanied or quickly followed by 
profuse diarrhea. The first vomitus and stools are made up of 
whatever happens to be in the stomach and intestines at the time 
of the onset. After that the vomitus and stools are composed al- 
most entirely of serum. The vomitus is often blood stained. The 
stools are large, watery, almost colorless and without odor. The 
reaction is usually acid in the beginning, but quickly becomes 
neutral and then alkaline. Microscopically they show large 



318 CHOLERA INFANTUM 

numbers of epithelial cells, a few leucocytes and very many bacte- 
ria. There is sometimes considerable tenesmus, but in most in- 
stances the sphincters are relaxed and the fluid simply runs out of 
the bowel every few minutes. There is no tenderness in the 
abdomen and no spasm of the abdominal muscles. The abdomen 
is usually sunken. The tongue is dry and red. 

There is very rapid emaciation as the result of the loss of fluid 
from the tissues. The face appears pinched, the eyes sunken, the 
skin dry and the fontanelle depressed. Thirst is a very marked 
and urgent symptom. The secretion of urine is much diminished. 
It is concentrated and highly acid. It usually contains albumin 
and sometimes casts and blood. 

On account of the accumulation of blood in the abdominal 
organs as the result of the vasomotor paralysis of the abdominal 
vessels and the consequent interference with the peripheral circu- 
lation, the extremities become cold and the skin pale and even 
cyanotic. The surface temperature is usually low, but the rectal 
temperature is high, ranging from 103° F. to 104° F. In fatal cases 
it may reach as high as 106° F. or even 108° F. 

The pulse is rapid from the beginning and soon becomes very 
feeble and irregular. The respiration is usually rapid and irreg- 
ular, but at times slow or sighing. It may be of the Cheyne- 
Stokes or Biot types. 

The infant is usually restless at first and whimpers almost con- 
stantly. After a time it becomes listless and stuporous or symp- 
toms of cerebral irritation develop. The head is retracted, the 
extremities are rigid and twitching and convulsions appear. 

Prognosis. — The prognosis is a very grave one. It is very 
seldom that a baby recovers from this disease. Death usually 
takes place during the first forty-eight hours after the onset. The 
disease seems to be self-limited, however, and if the baby survives 
for two or three days, it usually recovers. Recovery is ordinarily 
surprisingly rapid when the severity of the illness is taken into 
consideration. On the other hand, the acute symptoms may abate 
and be replaced by those of various types of indigestion. Sclerema 
sometimes develops under these conditions. The babies may even 
then recover, but ordinarily die after a period of malnutrition. 

Treatment. — In such a rapid and fatal disease it is evident that 
treatment, to be of any avail, must be immediate and vigorous. It 
is probable that there is a vasomotor paralysis of the gastrointes- 
tinal vessels. Hence food and drugs introduced into the alimentary 
canal cannot possibly be absorbed. They can do no good and 
undoubtedly may do harm. 



CHOLERA INFANTUM 319 

The main indications for treatment are: 1, to empty the stomach 
and bowels of their toxic contents; 2, to supply fluid to the tissues 
which are being so seriously drained; 3, to restore the surface 
circulation; 4, to reduce the temperature; 5, to keep the patient 
alive until the disease has run its course. 

Purgatives act too slowly to be of much use in this disease, and 
the chief reliance must be placed on stomach washing and intes- 
tinal irrigation. They are of use in the beginning, but do not do 
good after the first few hours. It is useless to expect to supply 
fluids by the mouth. They are almost invariably vomited. Cold, 
sterile water, in small amounts, may be tried, however. The in- 
jection of physiological salt solution into the cellular tissue is 
usually the best method of introducing fluid into the system. 
It should be given freely in doses of from four to eight ounces at a 
time and repeated almost as soon as it is absorbed. This not only 
supplies fluid to the tissues, but assists in eliminating the toxic 
substances from the blood and in restoring the surface circulation. 
If a sufficient amount cannot be given subcutaneously it should 
be given into the longitudinal sinus or intraperitoneally. 

Irrigations of cold water tend to restore the surface circulation 
and also to reduce the temperature. The best methods for re- 
storing the surface circulation are rubbing, mustard baths and the 
warm pack. These procedures, however, are not those best fitted 
for the reduction of temperature. For this purpose cold, in the 
form of sponging, fan baths or packs, must be used. In the treat- 
ment of individual patients it is often necessary to determine 
whether it is the internal congestion or the high temperature which 
is doing the more harm, and then to treat the more serious condi- 
tion. The relief of one, however, often aids the other also. 

As food cannot be given, the patient must evidently be kept alive 
by stimulation. As drugs given by the mouth are not absorbed, 
this stimulation must be given subcutaneously. The usual stim- 
ulants, strychnia, caffeine and camphor, are to be employed. 
Strychnia may be given in doses of from 1/1000 to 1/200 of a grain, 
subcutaneously. The dose of caffeine-sodium benzoate or sal- 
icylate is from one-eighth to one-half of a grain and that of cam- 
phor, one or two grains. The camphor should be given in oil. 
Atropine is especially useful in these cases. It is possible that it 
has some special action antagonistic to that of the toxic products 
of the disease. It is to be used in doses of from 1/500 to 1/800 of a 
grain, repeated every two or three hours, as necessary. Morphia is 
indicated when the diarrhea and vomiting are extreme or when the 
nervous manifestations are very marked. Doses of 1/100 of a 



320 CHOLERA INFANTUM 

grain are usually sufficient. They should be given subcutaneously. 
Care must be taken not to give too much or to continue it too long. 
In case improvement begins, stimulants and water may be given 
by the mouth, and soon after this, small amounts of food. The 
best food to give first in these cases is diluted human milk. It is 
wise to begin with one part of milk and two or three parts of 
water, giving from one-half to one ounce at a feeding. If this is 
tolerated, the strength and the amount at a feeding should be 
increased as rapidly as is possible. There are no very definite 
indications as to what combination of the food elements should be 
most suitable, when human milk cannot be obtained. The only 
thing that is certain is that the food must be a very dilute one. 
Whey is as likely to agree as anything. If this is tolerated, a mix- 
ture containing 0.25% of fat, 5% of milk sugar, 0.75% of whey 
protein and 0.25% of casein may be given next. If this agrees, the 
percentages of fat and casein should be gradually increased. If 
the whey does not agree with the baby, a mixture containing no 
fat, 2% of milk sugar, 0.75% of protein and 0.75% of starch should 
be tried. It is better to boil this mixture in order to prevent the 
formation of large, casein curds. If this mixture is tolerated, the 
percentages of milk sugar and casein should be increased and fat 
added cautiously. 






CHAPTER XXVI 

CONSTIPATION 

Constipation is not a disease. It is a condition in which the 
number of stools is less or the consistency of the stools is greater 
than is normal for the individual at the given time. 

CONSTIPATION IN THE NEW-BORN 

Constipation in the new-born must not be confused with those 
conditions in which the absence of stools is due to congenital 
malformations of the intestine, such as imperforate rectum and 
atresia of the intestine, which mechanically prevent the passage of 
feces. It is ordinarily due at this time to an insufficient intake of 
food, as the result of delay in the secretion of the breast-milk. In 
other instances, in which the supply of breast-milk or of artificial 
food is sufficient, the difficulty seems to be sluggishness of the 
intestinal peristalsis, apparently from lack of use, or an innate 
feebleness of the intestinal musculature. 

CONSTIPATION IN INFANCY 

Etiology. — The etiology of constipation in infancy is a very 
varied one and several factors are often active in the same case. 
The causes of constipation at this age can be divided into several 
classes, each of which can be further subdivided. These classes are 
so different that they must be considered separately. 

General Causes. — These causes, which should, perhaps, be called 
unclassified, are very different in their nature and in their action. 
They should always be thought of, however, in attempting to 
determine the cause of constipation. The first of these causes is 
heredity. The large number of instances in which constipation is 
present in both parents and infants makes it almost certain that 
heredity plays a part in the etiology of constipation in infancy. It 
is probable, however, that this part is a relatively minor one and 
that in most instances the presence of constipation in one or both 
of the parents and their infant is simply a coincidence. 

Insufficiency of the thyroid gland is another cause of constipa- 
tion in infancy which should always be borne in mind. It would, of 

321 



322 CONSTIPATION 

course, not be missed in well-marked cases of cretinism, but is 
easily overlooked when the characteristic signs of thyroid insuffi- 
ciency are slight or absent. 

An insufficient secretion of the intestinal glands or of the liver is 
presumably at the bottom of certain cases of constipation in in- 
fancy. It is very difficult, however, to recognize a deficiency in the 
secretion of these organs and to distinguish constipation from this 
cause from that due to minor errors in diet. 

Constipation is sometimes the result of the administration of 
opium, usually in the form of paregoric or " soothing syrup." 
This cause should never be forgotten in those instances in which no 
other evident cause can be determined. It must always be remem- 
bered in this connection, moreover, that the parents may not be 
aware that the baby is getting opium, because the drug may be 
given by a nurse or nursery maid without their knowledge. Con- 
stipation in a baby, otherwise apparently well, which is very quiet 
and which sleeps unusually well, should always suggest opium as its 
cause. 

Mechanical. — The large intestine is relatively longer in compar- 
ison to the small intestine in infancy than in later life and its 
mesentery proportionately longer. The sigmoid flexure makes up a 
relatively larger portion of the colon than later in life and its 
mesentery is comparatively long. These anatomical conditions 
render possible the production of bends and kinks of the colon 
which, while they do not obstruct the lumen of the gut entirely, 
hinder the passage of the intestinal contents through it and thus 
mechanically cause constipation. A Jackson's membrane or some 
other slight malformation in the vicinity of the cecum may also 
mechanically interfere with the free passage of the intestinal con- 
tents. So also may peritoneal adhesions, resulting from inflamma- 
tory processes in the past, whether before or after birth. Still 
another mechanical cause of constipation in infancy is congenital 
dilatation of the colon, or Hirschsprung's disease. In this conditon 
constipation often alternates with diarrhea. 

Tumors, most often in the pelvis, may also sometimes be the 
cause of constipation in infancy. In rare instances vesical calculi 
may be large enough to mechanically interfere with the passage of 
feces. 

Spasmodic. — Fissure of the anus may, on account of the pain 
which it causes during defecation, result in obstinate constipation. 
The pain attendant on a movement of the bowels not only makes 
the baby put off a movement as long as possible but also causes 
spasmodic contraction of the anal sphincter. Hemorrhoids, al- 



CONSTIPATION 323 

though rare in infancy, may cause constipation in the same way. 
Large, hard stools may also cause spasmodic constipation on ac- 
count of the pain attendant on their passage. This form of con- 
stipation is, for this reason, often a complication of other types. 
It may persist for a long time after the cause has been removed, 
the baby being afraid to have a movement because of its memory 
of the pain associated with it in the past. In rare instances a tonic 
spasm of the sphincter is the cause of the constipation. The 
etiology of the spasm in these cases is obscure. 

Dietetic. — Abnormalities in the food, either in its quantity or 
quality, make up one of the two most common of the classes of the 
causes of constipation in infancy. 

The most common abnormalities in breast-milk which result 
in constipation are an insufficient amount of milk, a dilute milk and 
a milk low in fat. The cause of the constipation is the same in all. 
The solids of the milk are so completely absorbed that there is not 
sufficient residue left to form the normal amount of feces. In rare 
instances a high percentage of fat in breast-milk is the cause of 
constipation. The explanation is the same as when there is a high 
percentage of fat in artificial foods. 

Constipation follows when an insufficient amount of an artificial 
food is given or when the food is too weak, because the solids of the 
milk are so completely absorbed that there is not sufficient residue 
left to form the normal amount of feces. An artificial food which is 
low in fat, although it contains a sufficient amount of carbohy- 
drates and protein, is also often accompanied by constipation. 
The cause of the constipation in this instance is the fact that 
the carbohydrates and protein are almost entirely absorbed and 
therefore make but a small amount of fecal matter, while a con- 
siderable proportion of the feces is derived from the fat in the food. 
A more common cause of constipation in the artificially-fed is an 
excess of fat in the food. In these instances the fat combines with 
the earthy alkalis to form the so-called " soap-stools.' ' These 
stools vary in color from light-yellow to gray. They are sometimes 
large and hard. In other instances they are dry and crumbly, 
resembling, in typical cases, the stools of a dog which has been 
eating bones. An excess of starch in the food may also cause con- 
stipation. When the constipation is due to this cause, the stools 
are large, brownish, dry and brittle. 

The heating of milk unquestionably predisposes to constipation, 
but only to a slight extent. It is a far less common cause of consti- 
pation than is ordinarily supposed. The boiling, or sterilization, of 
milk has more influence than does the pasteurization of milk, in 



324 CONSTIPATION 

fact, the pasteurization of milk at temperatures below 167° F. has 
almost no appreciable influence. 

One of the most common causes of constipation during the 
second year is the abuse of milk. A baby of this age should seldom 
take over thirty-two, or at most forty, ounces of milk in twenty- 
four hours. Constipation is very likely to result if more is given. 
Other causes of constipation at this time are an insufficient amount 
of cereal, orange juice and cooked fruit. 

Atonic. — Muscular weakness is the other of the two most com- 
mon causes of constipation in infancy. The intestinal muscles are 
always involved, while the abdominal muscles are not infrequently 
weakened at the same time. One of the most common causes of 
weakness of the intestinal musculature is prolonged indigestion, 
especially if associated with fermentation. Rickets is very fre- 
quently associated with atonic constipation. General malnutri- 
tion, anaemia and wasting diseases are other common causes of 
weakness of the intestinal muscles. 

Another cause of muscular weakness is lack of exercise. Many 
babies are kept too quiet and not allowed to use their muscles 
sufficiently to keep up their tone. In other instances the constipa- 
tion is due to the facts that the babies have not been trained to have 
a movement of the bowels at a regular time and have not been 
taught to use their muscles in defecation. It must be remembered 
in this connection that constipation in very young babies may be 
due simply to the lack of voluntary effort on their part to empty 
the rectum. * In such instances there are no general symptoms of 
constipation and the bowels move immediately if the rectum is 
stimulated in some way, as by the introduction of a suppository. 

A still further cause of what amounts to atonic constipation is 
the continued use of laxative drugs. These get the intestines into 
such bad habits that they do not respond to the normal stimulus. 

Symptoms. — It is very difficult to describe the symptoms of 
constipation in infancy. Constipated babies are often irritable and 
sleepless. They frequently show evidences of general discomfort. 
Their tongues are coated, their breath is foul and they suffer from 
flatulence and colic. All of these symptoms are, however, present 
in other conditions, especially in those which are not infrequently 
the cause of constipation. It is very difficult, therefore, in many 
instances, to determine what symptoms are due to the constipation 
and what to the primary condition. Pain during defecation is al- 
most invariably present in the spasmodic form. If the constipa- 
tion is due to trouble low down in the bowel, there are usually no 
general symptoms associated with it. 



TREATMENT OF CONSTIPATION 325 

Treatment. — The first element in the treatment of constipation 
in infancy is to establish the etiology, that is, to discover the 
cause of the constipation. This demands, in most instances, a very 
careful study of the diet and habits of the infant. Every detail has 
to be gone into. It also involves a careful physical examination 
including, in most instances, a rectal examination. The problem 
can often only be solved by the aid of Roentgenograms taken after 
bismuth meals or bismuth enemata. Abnormalities in the intestine 
interfering with the passage of the intestinal contents can often be 
discovered only in this way. A lack of general symptoms in con- 
nection with the constipation suggests that the trouble is in the 
rectum. If the introduction of a suppository is immediately fol- 
lowed by the passage of a normal stool, the rectum is certainly at 
fault. The general symptoms are most marked when the con- 
stipation is due to disturbance of the digestion in the small intes- 
tine. 

After the cause is discovered, the treatment must be directed to 
its removal. Certain causes, such as heredity, cannot, of course, 
be altered. Others, such as cretinism and the abuse of drugs, can 
be easily and quickly remedied. Time and the growth of the parts 
can alone remedy some of the mechanical conditions, such as the 
long infantile colon and sigmoid flexure. The other mechanical 
conditions demand operative interference. 

When the constipation is due to the pain caused by the passage 
of large, hard stools, measures should be taken to diminish the 
size of these stools and to make them softer by regulation of the 
diet and, if necessary, by the temporary use of mild laxatives. 
When the pain is due to hemorrhoids, they should be removed. 
Fissure of the anus can usually be quickly cured by keeping the 
stools soft and by the application of boracic acid ointment. The 
application of the nitrate of silver stick will help in some cases. 
Stretching of the sphincter is almost never necessary in infancy. 

The treatment of constipation due to errors in the diet is self- 
evident. When the dietetic errors are removed the constipation 
will cease. These errors can be determined in many instances, 
however, only by the most careful study of the diet and by the 
microscopic examination of the stools. 

The chief element in the treatment of the atonic form of con- 
stipation is the relief of the causative condition, whether it be 
rickets, malnutrition or anaemia. Another important element in 
these cases is the training of the baby to have a movement at a 
regular time and to use its abdominal muscles. If the condition is 
due to laxative drugs, they must be stopped. 



326 TREATMENT OF CONSTIPATION 

In most instances it is necessary to relieve the symptom, con- 
stipation, while the cause is being removed. The measures to be 
taken to accomplish this depend to a certain extent on the type of 
constipation present. When the constipation is due to muscular 
weakness, massage of the abdomen twice a day for from five to ten 
minutes is often of considerable assistance. It is of less value in 
the other types. Foods which stimulate the intestinal peristalsis 
are also of especial value in this form. Orange juice or prune juice, 
in doses of from one to four tablespoonfuls daily, may be given dur- 
ing the first year and baked apples and prune pulp during the 
second year. It is also allowable in some cases to give a few tea- 
spoonfuls of strained peas, string beans or spinach, or asparagus 
tips, daily, during the last quarter of the second year. Great 
care must be taken, however, not to disturb the digestion by giving 
an excessive amount of fruit and vegetables and thus to increase the 
constipation or to set up a diarrhea. It is rarely advisable to give 
bran, whether in the form of crackers, cookies, or rolls, to babies, 
although bran crackers can sometimes be used with advantage 
toward the end of the second year. 

If the stools are hard and dry, water, best given between the 
feedings, will often be helpful. Finely divided agar agar, in doses 
of from one to three teaspoonfuls daily, will often keep the feces 
moist and also increase their bulk. It should be mixed or cooked 
with the cereals or given in broth. Coarse foods are more likely to 
do harm than good in this form. 

The addition of oatmeal water or jelly to the food of a baby in 
the latter half of the first year, or the substitution of one of these 
for barley water, will sometimes aid in relaxing the bowels. In 
other instances, however, oatmeal has a constipating effect and 
barley water acts as a laxative. The substitution of one of the 
dextrins and maltose mixtures for milk or cane sugar sometimes 
relieves constipation in young babies. The greater the proportion 
of maltose, the greater, in general, is the laxative action. 

If these measures prove ineffectual, it is necessary to move the 
bowels by the administration of drugs by the mouth or by the 
stimulation of the intestine from below. When the cause of the 
constipation is in the rectum, stimulation from below is plainly 
indicated. When the seat of the trouble is higher up or is a more 
general one, it is often very difficult to decide which method to 
adopt. A good general rule is not to use the same method con- 
tinuously. There is less danger of establishing bad habits, if the 
methods are varied. 

There is more danger of making a baby dependent on stimula- 



TREATMENT OF CONSTIPATION 327 

tion of the rectum to produce a movement than of making it 
dependent on drugs. This is especially true of suppositories. It is 
very easy to educate a baby to think that it cannot have a move- 
ment of the bowels unless it is reminded of it by the introduction of 
a suppository. Great care must be exercised for this reason not to 
establish a bad habit in attempting to train a baby to have a 
movement at a regular time or on its chair. The simplest and 
least irritating type of suppository is a roll of paper dipped in 
sweet oil. Gluten suppositories are less irritating than glycerin 
suppositories. The soap-stick stands midway between them. 

The best and simplest form of enema is that composed of soap 
and water. No more should be given than is sufficient to produce 
the desired result. From two to four ounces is usually enough; 
more may be given if necessary. It is best given with a soft rubber 
ear-syringe. A fountain-syringe may be used, if desired. If the 
stools are hard and dry, an enema of from one-half ounce to one 
ounce of sweet oil, given to be retained, and followed later by a 
suds enema, if necessary, is often very useful. Glycerin enemas are 
inadvisable in the treatment of constipation in infants. 

The simplest laxative for a baby is milk of magnesia. One 
teaspoonful a day is usually sufficient, but more may be given, if 
necessary. It is best to give it all at one dose, preferably at the 
last feeding at night. Babies take it without question, if it is 
mixed with their milk. Most babies are not disturbed by it. In a 
few it causes considerable pain and discomfort and, therefore, has 
to be omitted. Babies very seldom become dependent upon it. 

If milk of magnesia is not well borne, phosphate of soda in doses 
of from ten to sixty grains may be substituted for it. This is also 
best given in the milk. 

During the latter part of the second year, phenolphthalein, in 
doses of from one to three grains is often useful. Cascara sagrada 
in doses of from one-half to one grain, or of from five to thirty drops 
of one of the liquid preparations, may also be used. 

Purgative drugs, such as castor oil and calomel, and to a less 
extent senna, should not be used continuously in the treatment of 
constipation. They are too powerful and have a secondary con- 
stipating action. Olive oil is useful in some cases. It must never 
be forgotten, however, that olive oil is a fat and that in those 
cases in which the constipation is due to an excess of fat in the 
food it will certainly exaggerate the condition. There is also 
danger, moreover, of disturbing the digestion with it. 



SECTION V 
DISEASES OF NUTRITION 

CHAPTER XXVII 
RICKETS 

Rickets is a constitutional disease which is almost certainly due 
to a disturbance of nutrition. All the organs and tissues of the 
body are affected, but the chief lesions are in the bones. These 
lesions are pathognomonic. Their chief characteristic is a local or 
general disturbance of the normal processes of ossification. Rick- 
ets is most common between the sixth and eighteenth months. It 
seldom occurs earlier and very rarely begins after the third year. 
It develops, therefore, at a time when the bones are in process of 
rapid development. 

Pathological Anatomy. — The bones grow in length through the 
formation of bone tissue in the cartilage between the epiphysis and 
diaphysis. They grow in thickness as the result of the growth of 
bone from the inner layers of the periosteum. As the bone in- 
creases in circumference, the medullary canal is enlarged propor- 
tionately by the absorption of the inner layer of bone. Under 
normal conditions these processes progress in regular order and in 
clearly defined lines. In rickets there is an overgrowth of the 
cartilaginous layer between the epiphysis and diaphysis both in 
width and thickness and it is markedly hyperemic. In this area 
the zone of proliferation is much enlarged and the cells are ar- 
ranged irregularly instead of symmetrically, as in normal condi- 
tions. The deposition of lime salts and the amount of calcifica- 
tion is, nevertheless, much less than under normal conditions. The 
epiphyseal centers of ossification are larger, softer and more 
vascular than normal. There is a similar disturbance in the sub- 
periosteal formation of the shaft. The outer layers of the shaft 
are thickened , but soft . The medulla of the bone is more hyperemic 
than normal and the inner layers of the bone also become softened 
through lack of lime salts. 

The visible results of these abnormalities in the growth of the 

329 



330 RICKETS 

bones are enlargement of the bones at the epiphyseal lines and at 
the centers of ossification and unnatural flexibility of the bones. 
On account of this increased flexibility, deformities and sometimes 
fractures are produced as the result of pressure or weight bearing. 

Etiology. — While there is but little doubt that rickets is due to a 
disturbance of the metabolism, chiefly of calcium and phosphorus, 
and that the bony changes are due to some interference with the 
deposition of lime salts, it is still a fact that the cause of rickets is 
not positively known. Many theories have been advanced, how- 
ever, as to its causation, all of which have a certain amount of 
evidence in their favor. 

Considerable importance has been attached to heredity as a 
predisposing factor in the etiology. It is believed that the pre- 
disposition is transmitted especially through the mother. Siegert * 
is the chief exponent of this theory. It has, however, received but 
little support. 

Another theory is that it is due to improper hygienic surround- 
ings and lack of fresh air and sunlight. Evidence in favor of this 
theory is that it is more common in the city than in the country, 
in the winter than in the summer, in the poor than in the well-to- 
do. It is also apparently more common in this country in those 
races whose new surroundings are most different from those to 
which they were accustomed. The children of a pastoral race are 
most likely to develop it when confined to a city. This is also 
true of wild animals. They never have the disease when free, but 
often develop it when confined in zoological gardens. 2 

The most generally accepted theory is that it is caused by im- 
proper food. Evidence in favor of this theory is that, other things 
being equal, it is much less common in the breast-fed than in the 
artificially-fed, unless lactation is unduly prolonged. It is also 
more common when the artificial feeding is bad than when it is 
rational. 

It has also been thought recently that it is infectious in origin. 3 
Certain animal experiments have seemed to give positive results. 
In these experiments a diplococcus was found in the bones 
of young animals which were clinically rachitic. 4 The evidence 

Siegert: Jaheb. f. Kinderh., 1903, lviii, 929. 

2 Lehnerdt: Ergebn. d. inn. Med. u. Kinderh., 1910, vi, 120. 

3 Oppenheimer and Hagenbach: Burkhardt quoted by Wieland in Bruneg 
and Schwalbe Handbuch der Allgemeine Pathologie und der Pathologischeri 
Anatomie des Kindesalters, Wiesbaden, 1913, ii, pt. I, p. 260. 

4 Morpurgo: Verhandl. d. Deutsch. path. Gesellsch., 1900, iii, 40, Ibid. 1909, 
xiii, 51; Schmorl: Ergebn. d. inn. med. u. Kinderh., 1909, iv, 403; Koch: 
Ztschr. f. Hyg. u. Infectionskr., 1911, lxix, 436. 



EXPERIMENTAL RICKETS 331 

in favor of the infectious origin of the disease is, however, not 
conclusive. 

Attempts have been made in recent years to prove that some 
of the diseases of metabolism, including rickets, are due to a dis- 
turbance of the function of certain of the glands which have an 
internal secretion. 

They are respectively the thyroid, parathyroid, adrenal and 
thymus glands (Mettenheimer, 1 Matti 2 ). Howland, and his asso- 
ciates 3 repeated the experiments on animals, using suitable con- 
trols, and were unable to produce rickets in any animals in which 
the thymus was removed. Renton and Robertson 4 have also 
recently shown that thymusectomy does not cause any symptoms. 
It seems, therefore, as if the work upon which was based the evi- 
dence that the thymus had some etiological relation to rickets, 
was not properly carried out. 

Kassowitz 5 believes that the increased vascularity of the bone 
marrow and epiphyses is the principal feature of rickets and ex- 
plains the abnormally wide zone of growth, and that these blood 
vessels erode the bone. 

Artificial Rickets in Animals. — Most investigators who have 
undertaken to reproduce rickets in animals have assumed that it 
is due to some disturbance in the calcium metabolism. They have 
assumed that it results from a calcium starvation because of too 
little calcium in the food, that there is sufficient calcium in the 
food but for some reason it is not absorbed in normal amounts, or 
finally that it is absorbed in normal amounts but the bones are 
unable to utilize it in the normal manner. Experiments on animals 
have given varying results. In most instances when animals have 
been fed on a food deficient in calcium, on an acid food or on a 
combination of the two, they have become clinically rachitic 6 with 
enlarged epiphyses. The microscopic appearance of such bones 
differs from that in true rickets in that the zone of proliferation is 
much narrower. Miwa and Stoeltzner's 7 experiments lead them 
to differentiate this condition from true rickets in infants and they 
give it the name of pseudorachitic osteoporosis. The bones from 
such animals have a very low ash and calcium content, but have 
not lost relatively as much magnesium as the bones in true rickets. 

1 Quoted by E. Wieland, loc. cit. 

2 Matti: Mitt, aus den Grenzgebieten der Med. u. Chir., 1911-12, xxiv, 665. 

3 Howland: Trans. Am. Ped. Soc., 1914, xxvi, 274. 

4 Renton and Robertson: Journ. Path, and Bacteriol., 1916, xxi, 1. 

6 Kassowitz: Jahrb. f. Kinderh., 1912, N. F. lxxvi, 369. 
6 Schmorl: Ergebn. d. inn. Med. u. Kinderh., 1909, iv, 403. 

7 Miwa and Stbeltzner. Beitr. z. path. Anat. u. allg. Path., 1898, xxiv, 578. 



332 CALCIUM METABOLISM 

In the former the loss of phosphoric acid goes hand in hand with 
the loss of calcium, while in the latter there is relatively less phos- 
phorus lost than calcium. 

Aron and Sebauer 1 produced artificial rickets in dogs without 
changing the calcium content in the muscles, although that in the 
bones was greatly diminished. This fact will be referred to again 
in the discussion of human rickets. 

Calcium Metabolism in Health and in Rickets. 2 — The skeleton 
of a newly-born baby, weighing 2600 grams, weighs 445 grams, 
the muscles 625 grams, the skin 379 grams, and the brain 342 
grams. 3 The dried bones of a newly-born infant contain 60% 
to 65% of ash and 40% to 45% of organic material. The amount 
of ash in the bone varies from birth onward. At first the ash 
increases, but during the second year it decreases to about 55%, 
with a corresponding increase in the organic material. At the 
end of the second year the ash again begins to increase until it 
reaches the 68% of the dried bone substance found in adults. 4 
The calcium oxide is distributed through the body in the following 
manner: muscles 0.03%, skin 0.02%, brain 0.107% and skeleton 
5.4%. There is in the whole body 25 grams of CaO. 5 Camerer 
and Soldner 6 give 1.019 grams to every 100 grams of body weight 
as the average amount of CaO in the newly-born. 

Schabad 7 says that the weight of the skeleton is 16% of the 
total body weight during the first year of life. The calcium con- 
tent of the skeleton is 1.25% of the body weight and 7.7% of the 
skeletal weight. The largest deposit of calcium takes plaee during 
the period of greatest growth, viz., in the breast-fed infant be- 
tween the second and fourth months and in the bottle-fed infant 
between the second and sixth months. 

Calcium in Milk. — Examination of the metabolism experiments 
in rickets shows that in artificial feeding the amount of calcium 
usually given is so large that there is no possibility of a calcium 
deficit in the food. When the infant is fed with human milk, the 
situation is different. The percentage of calcium may vary from 
0.03% to 0.08%, the lower limit of that taken by healthy nurslings 

1 Aron and Sebauer: Biochem. Zeitschr., 1908, viii, I. 

2 Much of this section is taken from Orgler: Ergeb. d. inn. Med. u. Kinderh., 
1912, viii, 142. 

3 Vierordt: Gerhardt's Handb. d. Kinderh., 1877, i, 53. 

4 Schabad: Arch. f. Kinderh., 1909-10, lii, 47. 

5 Brubacher: Zeitschr. f. Biol., 1890, xxvii, 517. 

6 Camerer and Soldner: Zeitschr. f. Biol., xxxix, 173; ad, 1900, 529; 1902, 
adiii, 1. 

7 Schabad: Arch. f. Kinderh., 1910, liii, 380. 



CALCIUM METABOLISM 333 

being about 0.034%, while the average is about 0.044%. The 
calcium content of milk decreases as lactation progresses from 
0.045% to 0.031%. 1 It is clear, therefore, that the milk secreted in 
early lactation will have a higher percentage than that in later 
lactation. This does not necessarily mean that the total daily 
amount of calcium received will be any different in early and late 
lactation, because in early lactation less milk is secreted than in 
later lactation. This may explain the fact why one nursling devel- 
oped rickets on 0.04% of CaO. 

Dibbelt 2 reports that he was able to increase the CaO content 
in human milk by giving Ca to the mother, but no subsequent 
investigators have been able to confirm these results. 3 

Calcium Requirements of Infants. — Orgler concludes after a 
long discussion that unless an infant absorbs at least 0.13 grams 
of CaO per day it will become rachitic. It must be borne in mind, 
however, that Tobler and Noll's 4 baby absorbed only 0.054 grams 
and yet did not acquire rickets. The average of the amount of cal- 
cium taken by all infants is between 0.17 grams and 0.18 grams. 
The normal infant takes as a rule only as much calcium from hu- 
man milk as it requires for growth. 5 It must be remembered in this 
connection, however, that the amount of some of the other food 
components may be so disproportionately high (for example fat) 
that the infant receives so many calories in a concentrated food 
that it does not take enough in amount to give it the amount of 
calcium it requires, even though the percentage of calcium is 
within normal limits. Infants have been reported to become ra- 
chitic receiving 0.088% CaO. 

Calcium Metabolism. — The methods of quantitating the salts 
in the food and excretions of the body are very difficult and certain 
authorities say that they are all unreliable with the exception of 
Macrudden's method for calcium. Since there is so much doubt 
as to the accuracy of the methods used in obtaining the following 
information, it must all be considered with the inaccuracies well 
in mind. 

Calcium is in the milk principally in organic combination. Both 
organic and inorganic calcium may be absorbed by the body. The 
calcium in the food goes into solution in the stomach. From 5% to 

1 Bahrdt and Edelstein: Jahrb. f. Kinderh., 1910, lxxii, 16 (Suppl.); Schabad: 
Jahrb. f. Kinderh., 1911, lxxiv, 511. 

2 Dibbelt: Ziegler's Beitr., 1910, xlviii, 147. 

8 Bahrdt and Edelstein: Jahrb. f. Kinderh., 1910, lxxii, 16 (Suppl.); Schabad: 
Jahrb. f. Kinderh., 1911, lxxiv, 511. 

* Tobler and Noll: Monatsschr. f. Kinderh., 1910-11, ix, 210. 

8 Aron: Biochem. Zeitschr., 1908, xii, 28. 



334 



CALCIUM METABOLISM 



10% of it appears in the urine after absorption, while the rest of the 
calcium that is not retained in the body is excreted through the 
feces. This may pass directly through the intestines into the feces 
or indirectly, viz. : it may be absorbed in the small intestine and 
excreted again in the large intestine. 1 Most of the calcium ex- 
creted in the urine is combined with phosphoric acid, but a small 
amount is combined with carbonic, sulphuric and uric acids. 2 

The most striking fact in the chemistry of rickets is that the 
bones in rickets as compared to the normal have a diminished 
amount of calcium and phosphorus and an increased amount of 
water. The following table taken from Orgler 3 illustrates this fact 
very well: 

This table was compiled by Orgler from Schabad: 4 



TABLE 49 



Normal 
Ribs Occiput 



Rachitis 
Ribs Occiput 



Water 

Organic substances 

Ash 

CaO 

P 2 6 



14.4-32.9 
26.9-39.1 
40.2-46.6 
21.7-25.3 
12.3-18.9 



13.0-16.1 
32.2-36.5 
47.6-51.7 
26.3-27.9 
18.1-20.7 



42.4-66.4 

20.7-27.4 

7.9-32.0 

4.2-16.8 

3.3-12.8 



29.0-35.9 
26.1-31.6 
34.3-40.6 
19.0-24.1 
13.7-17.8 



These changes are less marked in mild than in severe rickets. 

The Influence of the Other Food Components on the Calcium 
Metabolism. — Proteins. — There are very few experiments that have 
any bearing on the subject, but those that can be utilized 5 seem to 
show that the proteins have no influence on the calcium retention. 

Fat. — According to some writers fat has a marked influence on 
the calcium metabolism, as increased amounts cause a negative 
calcium balance. 6 The following table from Orgler serves to il- 
lustrate this point: 



1 First shown in dogs by E. Voit: Zeitschr. f. Biol., 1880, xvi, 55. 

2 Albu-Neuberg: Mineralstoffwechsel, Berlin, 1906, 116. 

* Made up from figures of Schabad: Arch f. Kinderh., 1909-1910, Hi, 47, 63; 
1910, liii, 380: 1910, liv, 83. 

4 Schabad: Zur Bedeutung des Kalkes in der Pathologie der Rachitis: Arch, 
f. Kinderh., 1910, lii, 47 and 63; 1910, liii, 380; 1910, liv, 83. 

5 Tada: Monatsschr. f. Kinderh., 1905-06, iv, 118. 

6 Freund: Jahrb. f. Kinderh., 1905, bri, 36. 



CALCIUM METABOLISM 



335 



TABLE 50 





/. Groeger 
(a) skim milk 
N CaO 


Rothberg l 

(6) cream 

N CaO 


Steinitz II, 2 
milk cream 
CaO CaO 


III 

En & Em 


2.963 
2.499 
0.315 


0.975 
0.020 
0.818 


3.400 
2.625 
0.381 


0.927 

0.0 

1.125 


0.398 
0.005 
0.355 


0.378 

0.0 

0.412 


Balance .... 


+0.149 


+0.137 


+0.394 


-0.198 


+0.038 


-0.034 



In other instances increasing amounts of fat in the food have 
no influence on the Ca metabolism, as is shown by the following 
work of Freund : 3 

TABLE 51 





Arndt 

5 /i2 milk 

water 

CaO 


Whole 
milk 
CaO 


Steinitz 
^2 milk 
CaO 


Cream 
CaO 


Food 


0.478 

0.0 

0.409 


0.857 
0.022 
0.467 


0.414 
0.387 


0.314 


Urine 




Feces 


0.216 






Balance 


+0.069 


+0.368 


+0.027 


+0.098 







Carbohydrates. — Up to recently there were no experiments free 
from error showing the influence of carbohydrate on the reten- 
tion of calcium. In 1913 Howland 4 reported the results of a study 
of the calcium metabolism as it was influenced by carbohydrates. 
A milk mixture without any carbohydrate was followed by a very 
slight positive or by a negative balance of calcium. When the 
same mixture was given with carbohydrate added, even though 
the carbohydrate was a small quantity of cereal, a positive calcium 
balance often resulted, and when sugar was given the calcium bal- 
ance was practically always positive. This work seems to indicate 
that carbohydrate has a very marked influence on the retention of 
calcium. There are no figures to show what effect an excess of car- 
bohydrate has on the calcium metabolism. 

Salts. — There are no studies to show the effect of the sodium or 

1 Rothberg: Jahrb. f. Kinderh., 1907, lxvi, 69. 

2 Steinitz: Jahrb. f. Kinderh., 1903, lvii, 689. 

3 Freund: loc. cit. 

4 Howland and Marriott: Am. J. Obstet., 1916, Ixxiv, 541. 



336 CALCIUM METABOLISM 

potassium salts on the retention of calcium in infants. The effect 
of an absence of organic material in the food, as in fasting, is also 
unknown. 

Cronheim and Muller 1 reported that boiling milk influenced 
the calcium retention, but Arndt, 2 who used better methods, 
showed that boiling had no effect on the retention of calcium. 

During the early stage of florid rickets 3 the calcium balance is 
either diminished or negative. This disturbance in the calcium 
metabolism may be present some time before the appearance of 
any of the clinical signs of rickets. 4 As the disease becomes well 
developed, the calcium balance is either below the average or 
within normal limits. When convalescence or cure commences 
there is a greatly increased retention of calcium, which shows itself 
earlier than does clinical improvement. During this period two or 
three times as much calcium is retained as in the normal, and when 
cure is complete the calcium retention again becomes normal. 

The increased excretion of calcium from the body in florid rick- 
ets goes on exclusively through the intestines, while at the same 
time there is less calcium than usual excreted through the 
urine. 5 

Phosphorus metabolism like the calcium metabolism is influenced 
by the kind of food given. 6 There is relatively so much phos- 
phorus excreted that it cannot all come from the bones and pre- 
sumably comes from the nervous system. 7 The relation between 
the urinary and fecal phosphorus in healthy nurslings is 80:20 and 
in rachitic nurslings 65:35, while in the healthy bottle-fed infant it 
is 60:40 and the rachitic artificially-fed 40:60. During conva- 
lescence from rickets the total excretion of phosphorus is lower 
than normal, and the relation of the urinary to the fecal phos- 
phorus returns to the normal figures. Calcium is excreted in the 
feces with phosphoric acid or fatty acid, and it is conceivable that 
an increase of either of these substances may increase the calcium 
excretion. 

Analyses of both rachitic and healthy bones show that the com- 
plex salt Ca 3 (P0 4 )2 2CaCC>3 is the same in both instances. Pota- 
sium, sodium and chlorine are the same in both. Magnesium is 

1 Cronheim and Muller: Jahrb. f. Kinderh., 1903, lvii, 45. 

2 Quoted by Orgler — loc. cit. 

3 Schabad: Arch. f. Kinderh., 1910, liii, 380. 

4 Birk and Orgler: Monatsschr. f. Kinderh., 1910-11, ix, 544. 

5 Schabad: Arch. f. Kinderh., 1910, liii, 380; Dibbelt: Verhandl. der Deutsch. 
path. Gesellsch., 1910, xiv, 294. 

6 Albu and Neuberg: loc. cit., p. 144. 
'Schabad: Arch. f. Kinderh., 1910, liv, 83. 



TREATMENT 337 

increased from 0.50% in the normal bone to 0.53-0.74% in rachitic 
bone. 1 

The muscles in rickets give evidence of the calcium loss from 
the body. They contain less calcium than do normal muscles, 2 
the amount of the deficiency varying directly with the severity 
of the disease. 

The calcium content of the other organs is not diminished in 
rickets. Pathologically, rachitic muscles show an excessive thin- 
ning of the muscle fibers with loss of striation, accompanied by an 
increase in the number of cell nuclei. These changes are most 
marked in the most severe cases. The blood in rickets shows very 
little or no diminution in its calcium content. 3 

Treatment. — What little evidence there is derived from experi- 
ments on animals goes to show that, while deficiency of calcium 
in the food causes a disturbance in the ossification of the bones, it 
does not produce rickets. It is evident, moreover, from the figures 
which have just been given, that there never is a deficiency of 
calcium in artificial foods, of which cow's milk forms the basis. 
There is, therefore, no justification whatever for giving calcium to 
rachitic babies that are taking cow's milk. It is barely possible, 
but extremely improbable, that a nursing baby may not get enough 
calcium in its food. Judging from the results of animal experi- 
mentation, such a deficiency would not, however, cause rickets. 
Nevertheless, it might be justifiable to give a breast-fed rachitic 
baby some form of calcium. There is no evident reason why one 
form of calcium should not be as useful as another under these 
circumstances. In any event, only a small amount would be 
required. It is probably useless to attempt to increase the calcium 
in the milk by giving calcium to the mother. If rachitic babies are 
taking neither human milk nor cow's milk and are, therefore, not 
getting enough calcium in their food, they should be given one or 
the other. It will then be unnecessary to give them calcium. It is 
possible that a baby that is taking a very rich food may take so 
little of it that it does not get enough calcium. The remedy for 
this condition is to dilute the food so that the baby will take more 
of it, rather than to give calcium. 

There are very few data as to the relation of the other food ele • 
ments to the metabolism of calcium. It is possible that the 
presence of a large excess of fat in the food may, by combining 
with the calcium in the food, interfere with its absorption and, 

^assmann: Hoppe-Seyler's Zeitschr. f. Phys. Chem., 1910-1911, lxx, 161. 

2 Aschenheim and Kaumheimer: Monatsschr. f. Kinderh., 1911-12, x, 435. 

3 Howland and Marriott: Tr. Am. Ped. Soc, 1916, xxviii, 200. 



338 TREATMENT 

therefore, with its retention. The evidence as to this fact is, how- 
ever, inconclusive. There is, on the other hand, a certain amount 
of evidence which goes to show that the addition of a carbohydrate, 
whether sugar or starch, to a food, the basis of which is cow's milk, 
favors the retention of calcium. Variations in the amount of pro- 
tein in the food have no apparent effect on the metabolism of 
calcium, but it must be remembered in this connection that a 
large part of the calcium in milk is in combination with protein, a 
deficiency of which might cause a deficiency of calcium. Neither 
do variations in the amount of sodium and potassium. There are 
no data as to the effect of variations in the amount of the other 
salts. 

Other things being equal, rickets is much less common and much 
less severe in breast-fed than in artificially-fed babies. The best 
food for the rachitic baby is, therefore, good human milk. If this 
cannot be obtained, the next best food must be selected. This is, 
necessarily, some form of modified cow's milk. There are no very 
definite general indications, based on our knowledge of the metabo- 
lism in rickets, as to what the composition of this food should be. 
What little experimental evidence there is, however, suggests that 
it is advisable to avoid high percentages of fat and to give per- 
centages of carbohydrates well up to the normal limits. These 
points should be borne in mind, therefore, in deciding upon the 
composition of the food. They are of but comparatively little 
importance, however, and should be disregarded if they conflict 
with the evidence furnished by the symptoms and stools as to the 
digestive capacity of the individual infant. The chief object in 
the selection of the food for the rachitic baby, as well as for all 
other babies, is to fit the food to the digestive capacity of the 
individual infant at the given time. That is, the composition of 
the food for a rachitic baby should be decided upon in the same 
way as that of any other baby, bearing in mind that perhaps it may 
be advisable to keep the percentage of fat lower and that of the 
carbohydrates higher then would ordinarily be done. 

There has been much discussion as to whether cod-liver oil and 
phosphorus, either alone or in combination, are of advantage in the 
treatment of rickets. It would seem fairly definite, however, from 
the experimental data as to the effect of large amounts of fat in 
the food on the metabolism and retention of calcium, that cod- 
fiver oil might not only do no good but perhaps active harm. 
Schloss * has found, however, that when cod-liver oil is given in 
connection with preparations of calcium the retention of calcium 
1 Schloss: Jahrbuch f. Kinderh., 1915, lxxxii, 435. 



TREATMENT 339 

is much better than when either is given alone. The evidence 
as to the action of phosphorus, whether alone or in combina- 
tion with cod-liver oil, which is summed up briefly below, is 
conflicting. 

Kassowitz ! first recommended phosphorus in the treatment of 
rachitis. His original prescription, known as phosphorleberthran 
(phosphori 0.01, ol. jecor aselli, ad 250), still holds first place in 
Germany in the treatment of rachitis. Kissel 2 found in his experi- 
ments on animals that phosphorus had absolutely no effect on the 
skeletal system, and concluded that there was no ground for its 
use. Despite this evidence phosphorus continues to be used and 
many experiments have been performed to prove its efficiency. 

Birk 3 and Schabad 4 both concluded that phosphorus in thera- 
peutic doses does not affect the calcium metabolism in healthy 
children. Such children take only as much phosphorus as they 
need for growth regardless of the amount in the food. In rachitis 
cod-fiver oil increases the retention of phosphorus and calcium and 
this action is intensified by the addition of phosphorus to the oil. 5 
The increased retention of calcium starts three to five days after 
giving phosphorus and gradually diminishes until at the end of 
two months it is again norma]. This is because of the increased 
absorption and decreased excretion through the urine and feces. 
The question then came up as to whether oils as such in combina- 
tion with phosphorus have a therapeutic action on rachitis. 
Schabad 6 investigated the action of phosphorus, cod-liver oil and 
"sesamol" on the metabolism of calcium, phosphorus, fat and 
nitrogen and found that "sesamol" and phosphorus did not help 
rachitis, while cod-liver oil plus phosphorus increased the retention 
of phosphorus and calcium and the absorption of fat and nitrogen. 
Schabad and Sorochowitsch 7 used lipanin, which is a mixture of 
olive oil and oleic acid and is used as a substitute for cod-liver oil. 
It is supposed to be easily absorbed because it contains free fatty 
acids. They concluded from their metabolism experiments that 
lipanin and olive oil increase the absorption of nitrogen and fat 
but that lipanin has no advantage over olive oil. Lipanin does 
not increase the retention of calcium in rachitis and is therefore 
not as good as cod-liver oil in the treatment of rachitis. They 

2 Kassowitz: Ztschr. f. klin. Med., 1883-4, vii, 36. 

3 Kissel: Virchow's Arch. f. path. Anat., 1896, cxliv, 94. 

4 Birk: Monatsschr. f. Kinderh., 1908-09, vii, 450. 
6 Schabad: Ztschr. f. klin. Med., 1909, lxvii, 454. 

1 Schabad: Ztschr. f. klin. Med., 1909, lxviii, 94. 

2 Schabad: Ztschr. f. klin. Med., 1909-10, lxix, 435. 

3 Schabad and Sorochowitsch: Monatsschr. f. Kinderh., 1910-11, ix, 659. 



340 TREATMENT 

say in their most recent article * that sometimes phosphorus and 
cod-liver oil does not have a favorable action on the retention 
of calcium in rachitis, especially if the disease is not approaching a 
convalescence. At other times it has a favorable action on the 
calcium retention. They experimented with various other salts 
combined with cod-liver oil and found that a calcium acetate cod- 
liver oil had the most favorable action on rachitis because it con- 
tained much more calcium. Most recently Caroline Towles 2 did a 
series of metabolism experiments in von Pirquet's clinic in Breslau 
and was unable to demonstrate that phosphorus cod-liver oil had 
any action at all on acute rachitis. 

It is very difficult to draw any conclusions from this evidence as 
to the advisability of using cod-liver oil and phosphorus in the 
treatment of rickets. It is probably safe to conclude, however, 
that it is not advisable to give large doses of cod-liver oil or any 
other fat. It is also probably safe to conclude that phosphorus may 
do good and that, at any rate, it does no harm if properly used. If 
phosphorus is used, it is probably best to give it in combination 
with cod-liver oil. The best preparation of phosphorus is phos- 
phorated oil. A minim of this preparation contains about 1/115 of 
a grain of phosphorus. The dose for a baby is from one-half of a 
minim to two minims, two or three times daily. Too much should 
not, however, be expected from it. It is liable to disturb the 
stomach and should be given after food. 

An abundance of fresh air and sunlight is of the greatest impor- 
tance in the treatment of rickets. Everything should be done to 
improve the hygienic surroundings. Massage undoubtedly does 
good. The advantage of salt baths is problematical. Iron should 
be given, if there is anaemia. Other treatment can be only symp- 
tomatic. 

1 Schabad and Sorochowitsch: Monatsschr. f. Kinderh., 1911-12, x, 12. 
■Towles: Ztschr. f. Kinderh., 1910-11, i, 346. 



CHAPTER XXVIII 

INFANTILE SCURVY 

Scurvy is a constitutional disease due to a disturbance of the 
nutrition. The disturbance of nutrition is the result of some pro- 
longed error in the diet. The error in the diet is in all probability 
the absence or marked diminution of some constituent or con- 
stituents of the food essential for the carrying on of the normal 
metabolic processes and for growth. It is not known exactly what 
these constituents are, but it is very probable that they are of the 
nature of vitamins. The chief characteristic of the disease is a 
tendency to hemorrhage. Infantile scurvy is the same disease as 
scurvy in the adult. Scurvy and rickets, although often asso- 
ciated, are two distinct diseases. 

PATHOLOGICAL ANATOMY 

The bone marrow shows characteristic changes. These are most 
marked at the ends of the diaphyses of the long bones and the an- 
terior ends of the ribs. The bone marrow, which is normally rich 
in lymphoid cells, loses it lymphoid character and is converted into 
a tissue poor in cellular elements, that contains relatively few 
blood vessels. This tissue consists of a homogeneous ground sub- 
stance containing spindle and stellate cells. There is still much 
calcified ground substance, but it has not been converted into 
true bone. As a result of the interference with the normal proc- 
esses of ossification, the cortex of the bones is thinner and more 
brittle than normal and the density of the bone is materially di- 
minished at the epiphyseal fine. Fractures of the shafts occur 
very readily, therefore, as the result of very slight injuries. These 
occur most often at or near the epiphyseal lines. The epiphyses 
are often loosened and separated. Marked displacement of the 
epiphysis, is, however, uncommon because the periosteum usually 
remains intact. 

The periosteum of the long bones is thickened and congested, 
but shows no excess of leucoctyes or small round cells. Hem- 
orrhages between the periosteum and the bone are very common 
and may be very extensive. They may break through the perios- 

341 



342 INFANTILE SCURVY 

teum into the surrounding tissues. Small hemorrhages in the 
marrow of the bones are also probably not at all uncommon, but 
can hardly be recognized clinically. Subperiosteal hemorrhages 
are much more common in the lower than in the upper ex- 
i remities. 

Hemorrhages may occur in any of the internal organs. They are 
common in the skin and are found at autopsy in most of the serous 
membranes. They may also occur in the intestinal mucosa. 
Hematuria, without inflammatory changes in the kidney, is com- 
mon. A hemorrhagic condition of the gums is a common symptom 
when the teeth have erupted. It is, however, very, uncommon 
before the teeth have appeared. Hemorrhage sometimes takes 
place in the orbit, pushing the eye forward, also under the dura 
or into the joints. 

There is enlargement of the heart in many instances. The right 
ventricle is chiefly involved and the enlargement is more often due 
to dilatation than to hypertrophy. 1 

Hess and Fish 2 have recently made a study of the blood in this 
disease to determine the cause of the hemorrhages. They found 
that the clotting power of the blood in scurvy was, as a rule, 
slightly diminished. This diminution was not, however, constant 
and cannot, therefore, be regarded as an essential manifestation 
of the disease or sufficient to account for the hemorrhagic tendency 
so characteristic of it. They found that there was no deficiency of 
calcium or blood-platelets and no excess of antithrombin. They 
then studied the blood vessels by means of what they term the 
" capillary resistance test" and found that there was a weakness 
of the vessel walls in scurvy. This weakness is also present in 
other conditions than scurvy and is, therefore, not pathognomonic 
of it. It seems evident from their work, however, that the hemor- 
rhagic tendency in scurvy is due to a weakness of the vessel walls 
rather than to any change in the blood. A firm edema, infiltrating 
the skin and muscles, not pitting on pressure, and most marked 
in the lower extremities is not uncommon and is also probably due 
to a nutritional disturbance of the smaller vessels. 3 

The increase in the rate of the pulse and respiration, the exagger- 
ated knee-jerks, and the cedema of the optic disks which has been 
found in some cases, suggest very strongly that the nervous sys- 
tem is also involved. 4 

1 Hess: Journ. Amer. Med. Ass., 1915, lxv, 1003. 

2 Amer. Jour. Diseases of Children, 1914, viii, 385. 
8 Hess: Journ. Amer. Med. Ass., 1915, lxv, 1003. 

4 Hess: Journ. Amer. Med. Ass., 1917, lxviii, 235. 



INFANTILE SCURVY 343 

ETIOLOGY 

Certain facts are definitely known as to the etiology of scurvy. 
One of them is that it occurs most frequently in the last half of the 
first year and in the first quarter of the second year. More than 
four-fifths of the cases develop during this period and half of them 
between the seventh and tenth months. It has been seen, however, 
in infants under one month old and occasionally develops during 
the third and fourth years. It is also true that the hygenic sur- 
roundings have no influence on its occurrence. The previous con- 
dition of health is unimportant and diseases of the digestive tract 
do not predispose to its development. Jackson and Moody 1 
and McCollum and Pitz 2 have recently called attention to the 
possibility that bacteria may be the cause of scurvy. They 
furnish, however, no evidence in any way satisfactory to prove 
that it is microbic in origin. 

Clinical experience apparently proves conclusively that scurvy 
is caused by some error in the diet. Furthermore, it seems to prove 
that it is due to some prolonged error in diet rather than to a tem- 
porary unsuitability of the food. The analysis of a considerable 
series of cases seems to show, moreover, that the disease is due to 
the lack of some essential element in the food rather than to the 
presence of some abnormal element or elements. Further than 
this the clinical evidence is rather unsatisfactory. It is true that 
scurvy is infinitely more common in artificially-fed infants than in 
the breast-fed. It does occur, however, in the breast-fed. This 
proves that it is not due simply to the lack of breast-milk. It oc- 
curs very frequently in babies that are taking proprietary foods 
prepared without milk. It occurs also in babies that are taking the 
proprietary foods prepared with milk and in babies that are taking 
milk without the addition of proprietary foods. These facts show 
that scurvy cannot be due simply to the presence of the proprietary 
foods or to either the presence or absence of milk in the diet. 
Scurvy occurs in babies that are taking condensed milk, boiled 
milk, pasteurized milk and raw milk, which apparently shows that 
the heating of milk, even if it is a factor in the production of scurvy, 
is not the only cause. The report of the Committee of the Amer- 
ican Pediatric Society in 1898 emphasizes the difficulties in ar- 
riving at the dietetic cause or causes of scurvy. They were only 
able to arrive at the conclusion, after a careful analysis of 379 cases, 
that "the farther a food is removed in character from the natural 

1 Jackson and Moody: Journ. Infect. Dis., 1916, xix, 511. 

2 McCollum and Pitz: Journ. Biolog. Chem., 1917, xxxi, 229. 



344 ETIOLOGY 

food of a child the more likely its use is to be followed by the devel- 
opment of scurvy." * The analysis of the authors' own cases shows 
the same discrepancy in the foods which were being taken when 
scurvy developed that has been found in all other series. It seems 
to show also, however, that the absence of "freshness" and the 
heating of the food are very important elements in the production 
of scurvy. In the more recent cases, overheating of the food was 
found in a larger proportion of the cases than was any other of the 
conditions to which it has been thought scurvy may be due. 2 

Effect of Heat. — It is very difficult to draw any positive conclu- 
sions from the literature of the subject as to whether the heating 
of milk, whether to the temperature of pasteurization or to that of 
boiling, produces scurvy in infants. The evidence presented is 
conflicting and inconclusive. In most instances the number of 
infants studied is small and the data as to the degree and duration 
of the heating are incomplete. The statistics of Variot 3 and Carel 4 
which are always brought forward to show that the heating of milk 
does not cause scurvy, are of little or no value, because at the time 
when these observations were made scurvy was not sufficiently 
well known in France to be recognized unless of a most extreme 
type. The strongest evidence against the heating of milk being the 
cause of scurvy is found in the work of Lane-Claypon in the Infant 
Consultation of the Naunyn Strasse in Berlin, in which a consider- 
able series of babies were fed on boiled milk for long periods and 
did not develop scurvy. 5 

The strongest clinical evidence in favor of the view that the 
heating of milk produces scurvy is the fact that all large series of 
cases of scurvy show that a considerable proportion of the patients 
were fed on heated milk, more of them, however, on sterilized, 
boiled or scalded, than on pasteurized milk. 6 It is impossible to 
prove, however, that it was the heating of the milk and not the 
composition of the food which caused the scurvy in these babies. 
It is evident that when an individual baby is fed on a heated mod- 

1 Archives of Pediatrics, 1898, xv, 481. 

2 Morse: Jour. Amer. Med. Assn., 1996, xlvi, 1073, Boston Medical and 
Surgical Journal, 1914, clxx, 504, and transoct. Amer. Ped. Soc, 1914, xxvi, 
61. 

3 Variot: Compt. rend. Acad. d. Sci., 1904, cxxxix, p. 1002. 

4 Carel: Le lait sterilise. These de Paris, 1902-3. 

5 Reports to the Local Government Board on Public Health, 1912, New 
Series, No. 63. The literature of the subject up to this time is given in this 
article. 

6 Sill: Medical Record, 1902, lxii, 1016; Hess and Fish: Amer. Jour. Dis. of 
Children, 1914, viii, 385; Morse, loc. cit: Report Amer. Ped. Soc'y Archives 
of Pediatrics, 1898, xv, 481. 



ETIOLOGY 345 

ified milk it is impossible to know, if scurvy develops, whether it is 
due in the special case to the heating or to the composition of the 
milk. It can be only a matter of opinion. Further evidence against 
the heating of milk causing scurvy is that scurvy sometimes devel- 
ops in the breast-fed and in babies fed on raw milk. Still further 
evidence are Plantanza's observations * that although scurvy de- 
veloped more frequently in babies fed on heated milk which was 
not used at once than on raw milk, it did not develop when fresh 
milk was heated and used at once. 

The results of experiments on animals with raw and heated milk 
are few and inconclusive. So many other factors have entered into 
the experiments that the results are practically without value. 
Frolich 2 was able to produce scorbutus in guinea pigs by exclusive 
feeding with either raw or cooked cow's milk, although not as per- 
fectly as by exclusive grain feeding. When fed on oats and raw 
milk they did not develop scorbutus, but when fed on oats and 
cooked milk they did. Bolle, and after him Bartenstein, 3 tried the 
effect of heating milk and found that heating it for a short time had 
no especial effect on guinea pigs. When, however, the milk was 
heated for a long time at a high temperature the guinea pigs died 
and single bones showed changes which Bolle identified as scor- 
butus. Moore and Jackson 4 found that when guinea pigs were fed 
on hay and milk, they developed scurvy whether the milk was 
given raw, pasteurized or boiled. The symptoms appeared most 
quickly when the milk was given raw. Furthermore, the addition 
of milk to an otherwise suitable diet caused scurvy. It seems 
evident, therefore, that no conclusions can be drawn as to the 
effect of the heating of milk in the production of scurvy in man 
from experiments on guinea pigs. 

Experimental Scorbutus in Animals. — Hoist and Frolich were 
the first to produce scorbutus in animals, in 1907. They and 
Fiirst continued their work for some years. 5 Talbot and Peterson 6 
repeated and confirmed their experiments. They found that when 
guinea pigs were fed exclusively on various forms of bread and 

1 Plantanza: Archiv. f. Kinderhielkunde, 1912, lvii, 155. 

2 Zeit. f . Hygiene u. Infectionskrankheiten, 1912, lxxii, 155. 

3 Bolle and Bartenstein: quoted by Hart, Virchow's Archiv. f. path. Anat. 
u. Phys., 1912, ccviii, 367. 

4 Moore and Jackson: Journ. Amer. Med. Ass., 1916, lxvii, 1931. 

5 Hoist and Frolich: Journal of Hygiene, Cambridge, 1907, vii, 619; Norsk 
Magazin for Laegevedenskaben, 1910, lxxi, No. 3; Zeit. f. Hygiene u. Infec- 
tionskrankheiten, 1912, lxxii, Part One; Furst: Norsk Magazin for Laegeved- 
enskaben, 1912, lxxiii, No. 1. 

6 Boston Medical and Surgical Journal, 1913, clxix, 232. 



346 ETIOLOGY 

grain, they died in from four to six weeks of a disease which in its 
symptoms and pathological anatomy corresponded with human 
scorbutus. They believed that the symptoms and pathological 
changes were caused by the diet. Others claimed, however, that 
they were the result of inanition from starvation. They then fed 
guinea pigs on fresh white cabbage, dandelions or carrots in such 
small amounts that the animals lost from 30% to 40% of their 
weight. None of these animals developed scorbutus, whereas ani- 
mals that were fed on dried grains or bread and lost a like amount 
of weight or relatively a few grams, showed scorbutic changes. 
These experiments proved conclusively that the scorbutic changes 
were not due to simple inanition. It is interesting to note in this 
connection that there are records of cases of human scorbutus 
which followed a diet which was the same or similar to that given 
to the guinea pigs. 

They found that scorbutus in guinea pigs is relieved or cured by 
fresh vegetables in the same way that it is in man. The anti- 
scorbutic properties of the vegetables are usually, if not always, 
weakened by the process of cooking, but are rarely entirely de- 
stroyed. There seems to be some connection between the in- 
tensity of the heat used in cooking and the loss of the therapeutic 
properties. For example, white cabbages are of less therapeutic 
value when they are cooked at from 110° C. to 120° C. than when 
they are boiled. 

The fresh vegetables lose their antiscorbutic properties in vary- 
ing degrees when they are dried. Among those which they in- 
vestigated are potatoes, carrots, dandelions and white cabbage. 
These vegetables are affected differently by drying. Dandelions 
lose their therapeutic value immediately on drying, while white 
cabbage retains it longer when kept in an open vessel in an incu- 
bator at 37° C. than when it is kept at room temperature. Freshly 
pressed cabbage juice quickly loses its antiscorbutic proper- 
ties when it is heated at from 60° C. to 100° C. for ten minutes. 
The same thing happens when it is preserved for a long time either 
at room temperature or in an ice chest. Pressed dandelion juice 
also loses its prophylactic properties when heated for a short time. 

In contradistinction to the above, lemon juice will withstand for 
a long time the same heat that will weaken or entirely destroy the 
virtue of white cabbage or dandelion juice. Raspberry juice can 
be cooked for one hour at 100° C. without losing any of its anti- 
scorbutic properties. Hoist and Frolich thought there must be 
some connection between the acidity of these juices and their 
antiscorbutic properties and they were able to increase the resist- 



ETIOLOGY 347 

ance of white cabbage and dandelion juice to heat by the addition 
of acids. They were not able to increase this resistance so that it 
would stand prolonged heating. They were unable to determine 
the nature of the antiscorbutic bodies by dialysis, by extraction or 
Other experimental methods. 

Fiirst 1 found that the feeding of guinea pigs exclusively on plant 
seeds would produce scorbutus, although not so easily and regularly 
as exclusively grain feeding. Plant seeds that produced scurvy 
acquired antiscorbutic properties when infected with fungi. He 
concluded from his experiments that neither the ash nor any of its 
alkalis plays any part in the incidence of scorbutus. There was 
no apparent connection between the fat, alkali, carbohydrate, 
cellulose or enzymes in the food and the appearance of the disease. 

Hart 2 was able to produce scorbutus, characteristic in both its 
symptoms and pathological anatomy, by feeding monkeys ex- 
clusively on trade condensed milk. They were kept in such good 
surroundings that they did not become rachitic. Control animals 
fed on a mixed diet did not develop scurvy. His results were 
confirmed by Dodd. 3 

Heubner and Lippschultz 4 fed dogs for many weeks on a food 
poor in phosphorus and found microscopic changes in the bones 
very similar to those found in scorbutus. 

Jackson and Moore 5 corroborated the findings of other observers 
that inanition does not produce scurvy and found further that 
cow's milk in any form not only does not cure scurvy in guinea 
pigs but causes it. Goat's milk, however, does not cause it. They 
also determined by experiments that the lactose in milk is not the 
cause of scurvy in guinea pigs and that scurvy is not due to a lack 
of lime salts. They call attention to the facts that a diet which 
is sufficient for growth and maintenance in one species may be ade- 
quate for another, sufficient for maintenance in another and pro- 
duce one of the deficiency diseases in a third, and that conclusions 
based on dietary experiments on one species of animals can be 
applied only to that species. 

The results of these experiments hardly justify any very positive 
conclusions as to the cause of scurvy. They show very definitely, 
however, that scurvy is not due to starvation and that it is not 

1 Zeit. f. Hyg. u. Infectionskrankheiten, 1912, lxxii, 121. 

2 Hart: Virchow's Archiv. f. path. Anat. u. Phys., 1912, ccviii, 367. 

3 Dodd: Boston Medical and Surgical Journal, 1913, clxix, 237. 

4 Huebner and Lippschultz, quoted by Hart: Virchow's Arch. f. path. Anat. 
u. Phys., 1912, ccviii, 367. 

6 Jackson and Moore: Journ. Infect. Dis., 1916, xix, 478; and Journ. Amer. 
Med. Ass., 1916, lxvii, 1931. 



348 METABOLISM IN SCURVY 

brought on simply by the long-continued use of a single article of 
food. They suggest very strongly that when scurvy develops as 
the result of the continuous use of a single food, the trouble with 
the food is not that it contains some substance which causes scurvy 
but that it lacks some substance which prevents scurvy. They 
also seem to show that this substance which prevents scurvy is 
partially or wholly destroyed by drying and heating. They do not 
show whether this hypothetical substance is a single definite en- 
tity or a group of substances, closely related to each other and 
similar in their action. 

The Metabolism in Scorbutus. — Very little is known as to the 
metabolism in scurvy. The only accurate study on the metabolism 
of scorbutus in adults is that of Baumann and Howard * who found 
that the loss of the various food constituents through the feces was 
less when fruit juice was added to the diet. The total sulphur 
metabolism was abnormal throughout the experiment, the quantity 
eliminated being in excess of that ingested. Chlorine and sodium 
were retained during the fruit juice period, but were excreted in 
excess of the intake during the preliminary period. More potas- 
sium, calcium and magnesium were retained during the fruit 
juice period than during the preliminary period. Lusk and Kloc- 
man 2 studied the metabolism of nitrogen and the mineral salts in 
a typical case of scurvy in an infant eighteen months old. Obser- 
vations were made for three periods of four days each; the first 
while the disease was at its height and the child was not being 
treated; the second, after a month's treatment; and the third, a 
month later, after all symptoms had disappeared. The nitrogen 
balance was normal at all times. The balance of mineral salts, 
particularly of calcium, was somewhat increased in the first period; 
in the second period during convalescence it was markedly de- 
creased; and in the third period was approaching, but had not 
reached, the normal, although the child was clinically well. This 
is in decided contrast to the condition in rickets. Bahrdt & Edel- 
stein 3 obtained very different results from their analysis of the 
organs of an eight months' old baby dead of scurvy, which showed 
no signs of rickets. The ash of the bones was much less than nor- 
mal. They contained only from 1/5 to 1/3 of the normal amount 
of calcium and there was a corresponding diminution in the phos- 
phorus. The sodium and potassium were somewhat increased. 
There was also a diminution in the calcium in the muscles. The 

1 Baumann and Howard: Archives of Internal Medicine, 1912, ix, 665. 

2 Lusk and Klocman: Jahrb. f. Kinderheilkunde, 1912, lxxv, 663. 

3 Bahrdt & Edelstein: Ztschr.f. Kinderheilk, 1913, ix, 415 and 1914, x, 352. 



VITAMINS 349 

amount of salts in the other organs was apparently normal. These 
studies, while interesting, show nothing, however, as to the etiology 
of this disease. 

The Vitamins. — Funk has recently called attention to the sig- 
nificance of the so-called vitamins in physiology and pathology, 
especially in relation to the etiology of what he calls the "avita- 
minoses," namely, beriberi, scorbutus, pellagra and rickets. 1 
He believes, and advances strong evidence to prove, that these 
diseases are due to the absence of certain vital substances in the 
food, that is, the vitamins. He shows from this own work and 
that of others that milk contains a considerable number of these 
antiscorbutic substances as well as a substance which materially 
favors the growth of young animals. The development of scurvy 
in infants taking foods which contain no milk may be explained, 
therefore, by assuming that these foods do not contain the essen- 
tial vitamins which milk does contain. The vitamins are, in 
general, very sensitive to heat. Those in milk are relatively stable. 
They are, however, partially destroyed by heating milk for a short 
time, and totally destroyed by long heating or sterilization. The 
development of scurvy in babies taking heated milk and the 
greater frequency of the disease when the food is boiled or sterilized 
than when it is pasteurized may be explained by assuming that the 
vitamins are partially or wholly destroyed by the heating, the 
destruction being more or less complete according to the degree 
and duration of the heating. Scurvy sometimes develops, however, 
in babies that are taking raw milk, or even in those that are on 
the breast. His explanation of the development of scurvy on a 
diet of raw milk is that in such instances the milk is deficient in 
vitamins. In support of this explanation he brings forward evi- 
dence to show that the amount of the vitamins in the milk varies 
with the amount of the vitamins in the food of the cows. An 
example of the influence of the food of the cows upon the amount 
of vitamins in the milk is the fact that their milk contains less 
vitamins in the winter, when they are eating dry food, than in 
the summer, when they are eating green food. The develop- 
ment of scurvy in infants on the breast may be explained in a 
similar way. He calls attention to the fact, moreover, that 
the vitamins are diminished in the milk of women who are 
underfed. 

Many objections can be raised to Funk's arguments and it may 
be urged that his premises are incorrect and his conclusions con- 

1 Casimir Funk. Die Vitamine, etc., Wiesbaden: J. F. Bergman, 1914. 



350 VITAMINS 

sequently not justified. Nevertheless, his proposition that scurvy- 
is caused by the diminution or absence of certain essential vital 
elements, or vitamins, in the food, reconciles and explains the 
clinical facts and experimental evidence as to the etiology of this 
disease better than any other which has been advanced. 

Hess * calls attention to the fact that enlargement of the heart, 
edema and nerve degeneration, which occur in scurvy, are per- 
manent symptoms in beriberi, which is without question a de- 
ficiency disease, and considers it a strong argument that scurvy 
is also a member of this group. The improvement of babies with 
scurvy when wheat middlings are added to the diet he considers 
further proof. 

McCollum and Davis 2 concluded from their studies of rats which 
failed to grow and live on diets composed of purified food ele- 
ments that there were lacking in such food mixtures two essential 
substances, or groups of substances. McCollum and Kennedy $ 
think that the term vitamins does not adequately describe these 
substances and prefer the terms "fat-soluble A" and "water- 
soluble B" for them. The first is found in abundance in butter- 
fat and egg-fat and the latter in the leaves of plants, but only to a 
small amount in their seeds. 

McCollum and Pitz 4 found, as did Jackson and Moore, 5 that the 
addition of milk to a diet of oats did not prevent the development 
of scurvy in guinea pigs, and conclude, therefore, that the lack of 
"fat-soluble A" cannot be the cause of scurvy. They also con- 
clude from a series of experiments on rats that the "water-soluble 
B" must have been present in the oats. Therefore, they believe 
that scurvy in the guinea pig cannot be due to a lack of any specific 
substance of this class. Consequently they conclude that scurvy 
is not a deficiency disease in the sense in which the term has re- 
cently been used. 

They found in guinea pigs which died of scurvy on a diet of 
oats and milk, the stomach, small intestines and lower colon were 
empty while the cecum was distended with putrefying feces. The 
cecum of the guinea pig is very large and delicate. They argue, 
therefore, as follows : The guinea pig can thrive only on a diet which 
leads to the formation of bulky and easily eliminable feces. Diets 

1 Hess: Journ. Amer. Med. Ass., 1915, Ixv, 1003. 

2 McCollum and Davis: Journ. Biol. Chem., 1915, xxiii, 181. 
* McCollum and Kennedy: Journ. Biol. Chem. xxiv, 491. 

4 McCollum and Pitz: Journ. Biol. Chem. 1917, xxxi, 229. 
6 Jackson and Moore: Journ. Infect. Dis., 1916, xix, 478, and Journ. Amer. 
Med. Ass., 1916, lxvii, 1931. 



TREATMENT 351 

such as oats do harm only in that they form pasty feces which 
cannot be passed out of the delicate cecum. Putrefaction occurs, 
which injures the cecal wall, which allows the passage of bacteria 
or toxins, which by their action on the walls of the capillaries 
produce the characteristic symptoms of scurvy. They found 
further that the addition of laxatives to the food which produced 
scurvy prevented or delayed its development. They believe that 
orange juice does good simply because of its laxative action. They 
do not go so far as to claim that the cause of scurvy in infancy is 
colonic stasis with the absorption of toxins or bacteria, but think 
that their experiments lend support to this belief. The chief 
objections to their arguments are that conclusions based on dietary 
experiments in one species of animals cannot be applied to others 
or those on animals to man, that the infantile cecum is not especially 
large or delicate and that laxatives do not cure scurvy in infants. 



TREATMENT 

There is nothing in the pathological changes, in the causes 
underlying the hemorrhagic condition, or in the results obtained 
from studies of the metabolism in this disease which yields any 
information of value as to its treatment. The clinical and experi- 
mental evidence all goes to show, however, that the disease is 
due to the lack of some essential element or elements in the food, 
probably belonging to the class of vitamins. This same evidence 
also shows that these elements are likely to be deficient in foods 
which do not contain milk. It shows, too, that they are present in 
milk and that they are weakened or destroyed when milk is heated, 
the effect of the heating apparently depending on the degree of 
heat and the duration of the heating. They are almost invariably 
present in sufficient quantities in human milk. 

The indications furnished by this evidence as to the preventive 
treatment of scurvy are obvious. Babies should be nursed, when- 
ever this is in any way possible. If the supply of breast-milk is 
insufficient, they should be given all that there is in order to make 
up for any possible deficiency in the antiscorbutic elements in the 
artificial food. If it is necessary to use an artificial food, the basis 
of this food should be milk, which contains antiscorbutic elements. 
Unless the use of raw milk is for some reason contraindicated, the 
milk should be given raw, because heating milk almost certainly 
weakens its antiscorbutic properties. If it is necessary to heat the 
milk, it should be pasteurized at the lowest temperature con- 
sistent with safety, in order that these properties may be weakened 



352 TREATMENT 

as little as possible. If it is necessary to use heated milk con- 
tinuously, antiscorbutics should be given in addition. Babies 
should not be given foods for any considerable length of time 
which do not contain milk. 

It has been known for many years that fresh vegetables and 
fruits contain elements which cure scurvy. The antiscorbutic 
properties of fruits are in general greater than those of vegetables. 
These properties are present in the fruit juices. Fruit juices can 
be easily given to babies; vegetable and vegetable juices are less 
suitable for them. The most available fruit juices are those of 
the lemon and orange. Babies prefer the taste of orange juice to 
that of lemon juice and it is less likely to disturb the digestion. 
Orange juice should be used, therefore, in the treatment of scurvy, 
if it is easily procurable. It should be given in doses of one ounce 
daily. Less than this amount is liable to be ineffective, and ex- 
perience has shown that more than this is unnecessary. It is 
best given in one dose, one hour before a feeding, when the stomach 
contains but little milk. It is less likely to disturb the digestion if 
given in this way. There is no objection to diluting it with water 
or to adding cane sugar to it, if the babies object to it plain. The 
boiling of orange juice does not lessen its therapeutic value. It 
does not, however, increase it. There is, therefore, no object in 
boiling it. The juice of the orange peel also contains antiscorbutic 
elements. 1 The only reason for using it instead of orange juice 
is for the sake of economy. 

Since orange juice and lemon juice are so easily procurable, and 
since they are probably the most powerful antiscorbutics, it hardly 
seems necessary to consider vegetables and other fruits, even 
though they also will cure scurvy. An exception may perhaps 
be made in the case of potato, which is easily procured and inexpen- 
sive. The potato should be boiled and mashed and given in doses 
of at least a tablespoonful daily. Hess and Fish 2 have suggested 
the use of potato water, made by mixing one tablespoonful of 
boiled and mashed potato in a pint of water, instead of the cereal 
waters in the preparation of foods for infants as a preventive of 
scurvy. Hess 3 found that wheat germ and wheat middlings did not 
have enough antiscorbutic power to make them of value from 
either a practical or clinical standpoint. There is no apparent ad- 
vantage in the use of alcoholic extracts of vegetables, as suggested 

1 Hess and Fish: Amer. Jour. Dis. of Children, 1914, viii, 385. 

2 hoc. tit. 

3 Hess: Journ. Amer. Med. Ass., 1915, lxv, 1003 and Amer. Journ. Dis. of 
Ch., 1917, xiii, 98. 



TREATMENT 353 

by Freise, 1 even if they will cure scurvy, when fruit juices are so 
easily procurable. 

Scurvy can also be cured by a change in the character of the food. 
Human milk will cure scurvy. The substitution of a food con- 
taining milk for one which does not or stopping the heating of 
the milk will usually cure it. Recovery is slow under these cir- 
cumstances, however, while it is very rapid when orange juice is 
given. It is inadvisable, therefore, to trust to a change in the food 
to cure the disease. Orange juice will cure it, even if the food 
which caused the scurvy is continued. It is wiser, however, to 
change the food unless there is some special reason in connection 
with the baby's digestive capacity for continuing it. 

Cod-liver oil and olive oil do not either prevent or cure scurvy. 

Yeast, whether autolyzed or dessicated, has no value either as a 
prophylactic or curative agent. 2 There are no drugs which have 
any influence upon it. 

1 Freise: Monatschr. f. Kinderheilk., 1914, xii, 687. 

2 Hess: Amer. Journ. Dis. of Ch. 1917, xiii, 98. 



CHAPTER XXIX 
SPASMOPHILIA 

Spasmophilia is a constitutional anomaly which presents and is 
recognizable by a characteristic mechanical and electrical overex- 
citability of the nervous system and which produces a pathologic 
predisposition to certain partial and general clonic and tonic con- 
vulsions. 1 Its most familiar manifestations are tetany, laryn- 
gismus stridulus and convulsions. The best known signs of the 
increased mechanical overexcitability of the nervous system are 
Trousseau's sign and Chvostek's sign, or the facial phenomenon. 
Erb's sign is the name given to the peculiar quantitative reaction 
of the nerves to the galvanic current. Thiemich and Mann 2 
worked out a typical law of contraction for this condition a number 
of years ago. For practical purposes, however, it is sufficient to 
remember that the appearance of cathodal opening contractions 
under 5 ma is pathognomonic of spasmophilia and that the ap- 
pearance of anodal opening contractions with less current than 
that causing anodal closing contractions is very strong evidence 
in favor of it. 

Pathological Anatomy. — There are no characteristic patholo- 
gical lesions in spasmophilia. Various lesions of the parathyroids 
have been found in some instances, but it is very doubtful if these 
lesions have any direct connection with the disease. 

Etiology. — rMuch has been written in recent years as to the eti- 
ology of spasmophilia, but as yet no absolutely positive conclusions 
are justified. The best summaries of the literature of the subject 
in English are to be found in the articles of Reye, Brown and 
Fletcher, Gamble and Grulee. 3 

Heredity. — It has long been recognized that spasmophilia is often 
hereditary or familial in type. 4 It is self-evident, however, that 
heredity is not the chief factor in the causation of this condition, 

1 Pfaundler and Schlossmann: The Diseases of Children, 1908, iv, 289. 

2 Thiemich and Mann: Jahrb. f. Kinderh., 1900, li, 99 and 222. 

3 Reye: Archives of Pediatrics, 1914, xxxi, 664; Brown and Fletcher: Amer. 
Journ. Dis. Child., 1915, x, 313; Gamble: Amer. Journ. Dis. Child., 1917, xiii, 
384; and Grulee: Amer. Journ. Dis. Child., 1917, xiii, 44. 

4 Thiemich in Pfaundler and Schlossmann: The Diseases of Children, 1908, 
iv, 285; Schiffer: Jahrb. f. Kinderh., 1911, lxxiii, 601; Sedgwick: Amer. Journ. 
Dis. Child., 1914, vii, 140. 

354 



CALCIUM METABOLISM 355 

because in the vast majority of cases there is no evidence of hered- 
ity. Moreover, when it occurs in several members of the same 
family, environment affords as good an explanation of its occurrence 
as heredity. Furthermore, a neuropathic family history is lacking 
in a majority of the cases. In cases in which there is a neuropathic 
family history, it is possible that a nervous system of low resistance 
may have been transmitted and predispose to the development of 
this condition. It is certain that heredity can play no larger part 
than this in its etiology. 

Calcium Metabolism. — Most of those who have made a study of 
spasmophilia in recent years connect it with a disturbance of the 
calcium metabolism, the great majority believing that it is due to 
a deficiency of calcium in the tissues. Stoeltzner 1 thought from 
his experiments that spasmophilia was due to an increase in the cal- 
cium content of the tissues. His results were, however, quickly dis- 
proved by Riesel. 2 No one has found an increase in the calcium re- 
tention in this disease. On the other hand, experiments have failed 
to show that there is constantly a diminished or negative calcium 
balance. 3 

Quest, 4 however, found that the calcium content of the brains of 
two infants dead of spasmophilia was considerably lower than that 
of the brain of a normal infant. Aschenheim 5 confirmed his findings 
but Cohn 6 did not. MacCallum and Voegtlin 7 also found a dim- 
inution in the amount of calcium in the brain and spinal cord of 
dogs with experimental parathyroid tetany. Katzenellenbogen 8 
found a diminution in the calcium of the blood in four out of five 
infants with spasmophilia, while Howland and Marriott, 9 using a 
new and accurate method of their own, found that the calcium 
content in spasmophilia was regularly low. They also found a dim- 
inution in the calcium content of the blood of dogs ill with ex- 
perimental tetany after parathyroidectomy. So also did MacCal- 
lum and Vogel. 10 

1 Stoeltzner: Jahrb. f. Kinderh., 1906, lxiii, 661. 

2 Riesel: Archiv. f. Kinderh., 1908, xlviii, 165. 

3 Cybulski: Monatschr. f. Kinderh., 1906, v, 409; Schabad: Monatschr. f. 
Kinderh., 1910, ix, 25; Schwartz and Bass: Amer. Journ. Dis. Child., 1912, iii, 
15. 

4 Quest: Jahrb. f. Kinderh., 1905, bri, 114 and Wien. klin. Woch., 1906, xix, 
830. 

6 Aschenheim: Monatschr. f. Kinderh., 1910, ix, 366. 

6 Cohn: Deutsch. Med. Woch., 1907, xxxiii, 1987. 

7 MacCallum and Voegtlin: Journ. Exp. Med., 1909, xi, 118. 

8 Katzenellenbogen: Ztschr. f. Kinderh., 1913, viii, 187. 

9 Howland and Marriott: Trans. Amer. Ped. Soc, 1916, xxviii, 200. 

10 MacCallum and Vogel: Journ. Exp. Med., 1913, xviii, 618. 



356 CALCIUM METABOLISM 

Rosenstern ! was able to reduce the electrical excitability in in- 
fants with spasmophilia by giving large amounts of calcium salts 
by mouth. Zybell 2 was also able to reduce the electrical excita- 
bility by giving large amounts of calcium salts, but thought that 
the results from small doses were inconclusive. 

It is generally believed that calcium and magnesium salts tend 
to lower nervous irritability and that sodium and potassium salts 
tend to increase it. That is, these salts act antagonistically to each 
other. Reiss 3 has expressed this proposition by the following for- 
mula: — — r~^r* Spasmophilia can thus be explained by a dim- 
Na + K 

inution in the calcium and magnesium salts in the tissues. The 
data just given are evidence in favor of this explanation, as far as 
regards calcium. There are practically no data as to magnesium. 
Theoretically spasmophilia might equally well be due to an in- 
crease in the sodium and potassium salts in the tissues. Aschen- 
heim 4 found an absolute increase of these salts in the brain tissue 
of infants dead of spasmophilia, as well as a diminution in the cal- 
cium. Zybell 5 was able to increase the electrical excitability in spas- 
mophilia by giving large doses of acetate of potash and Rosenstern 6 
by large doses of sodium chloride, while MacCallum and Voegtlein 7 
were able to increase the severity of the symptoms of tetany in para- 
thyroidectomized animals by the injection of sodium and potas- 
sium salts. Lust 8 described a case of tetany in an infant of two 
years in which there was also marked edema. The symptoms of 
tetany disappeared and reappeared coincidently with the dis- 
appearance and reappearance of the edema. He concluded from 
this observation that the spasmophilia was due to an increase in 
the sodium chloride retention. Brown and Fletcher 9 have called 
attention to the improvement in the symptoms of spasmophilia 
when diarrhea occurs and attribute it to the loss of sodium and po- 
tassium in the stools. They quote in favor of this view the obser- 
vation of Holt, Courtney and Fales 10 who found that there was a 

1 Rosenstern: Jahrb. f. Kinderh., 1910, lxxii, 154. 

2 Zybell: Jahrb. f. Kinderh., 1913, lxxviii, 29. 

3 Reiss: Ztschr. f. Kinderh., 1911, iii, 1. 

4 Aschenheim: Jahrb. f. Kinderh., 1914, lxxix, 446. 

5 Zybell: Jahrb. f. Kinderh., 1913, lxviii ; 29. 

6 Rosenstern: Jahrb. f. Kinderh., 1910, lxxii, 154. 

7 MacCallum and Voegtlein: Journ. Exp. Med., 1909, xi, 118. 

8 Lust: Munchen. Med. Woch., 1913, vi, 93. 

9 Brown and Fletcher: Amer. Journ. Dis. Children, 1915, x, 313. 

10 Holt, Courtney and Fales: Amer. Journ. Dis. Children, 1915, ix, 
213. 



THE PARATHYROIDS 357 

much greater loss of sodium and potassium than of calcium and 
magnesium in diarrheal stools. They believe that spasmophilia is 
due to an increased retention of sodium and potassium in the tis- 
sues as the result of water retention on improper foods and of con- 
stipation, and present their study of one case in favor of their 
belief. Grulee 1 concludes from his studies that there is strong evi- 
dence of a definite relation between increased electrical irritability 
and the retention of sodium and potassium salts, but does not think 
that the action of the sodium and potassium salts is due primarily 
to retention of water in the system. 

Parathyroids. — It is a well-known fact that tetany can be pro- 
duced experimentally in dogs by extirpation of the parathyroids. 
Tetany also develops in man after operations for goitre, if the 
parathyroids are not saved. As soon as these facts were noticed 
many writers at once attempted to prove that experimental para- 
thyroid tetany was the same condition as postoperative human 
tetany and that both were identical with spontaneous human tet- 
any. 2 It was a logical sequence to conclude that spasmophilia 
was due to insufficiency of the parathyroids. Efforts were then 
made to determine if there was any pathologic or anatomic evi- 
dence for or against this conclusion. Thiemich 3 found nothing 
abnormal in the parathyroids of three spasmophilic and five nor- 
mal infants. Erdheim 4 and others found that hemorrhages not 
infrequently occurred in the parathyroids during birth as the re- 
sult of asphyxia. Yanase 5 found the parathyroids normal in thir- 
teen infants who during life showed normal electrical reactions, 
while twelve of twenty-two, or 54.5%, who showed an increase in 
electrical excitability had hemorrhages in the parathyroids. He 
believed, therefore, that the hemorrhages interfered with the func- 
tions of the parathyroids and that this interference resulted in 
spasmophilia. Others, however, notably Auerbach, 6 found evi- 
dences of hemorrhages in the parathyroids of two-thirds of the 
children with normal irritability. They concluded, therefore, that 
the anatomical evidence in favor of a connection between the para- 
thyroids and spasmophilia was unconvincing. Haberfeld 7 and 
others think that spasmophilia is not due to changes in the para- 
thyroids caused by hemorrhages at birth, but to disturbance of 

1 Grulee: Amer. Journ. Dis. Children, 1917, xiii, 44. 

2 Reye: Archives of Pediatrics, 1914, xxxi, 664. 

3 Thiemich: Jahrb. f. Kinderh., 1900, li, 99, 222. 

4 Erdheim: Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1906, xvi, 632. 
6 Yanase: Jahrb. f. Kinderh., 1908, lxvii, 57. 

6 Auerbach: Jahrb. f. Kinderh., 1911, lxxiii, Supp. 193. 

7 Haberfeld: Wien. Med. Woch., 1910, lx, 2691. 



358 THE PARATHYROIDS 

their function. It is obvious that it is difficult to prove or dis- 
prove this assumption. 

On the chemical side MacCallum and Voegtlein 1 found a dimi- 
nution in the calcium in the blood and brains of parathyroidectom- 
ized dogs. Howland and Marriott 2 also found a diminution in the 
calcium content of the blood of parathyroidectomized dogs. Mac- 
Callum, Lambert and Vogel 3 have recently shown indirectly, by 
the use of the dialysis method of Abel, Rowntree and Turner, that 
there is a diminution in the calcium content of the blood in para- 
thyroidectomized dogs. These findings suggest strongly that, if 
it is accepted that spasmophilia is caused by a diminution in the 
amount of calcium in the tissues, the disturbance of the calcium 
metabolism is due to an insufficiency of the parathyroids. Wilson 
and his co-workers 4 have recently shown that a disturbance of 
the acid-base balance in the body develops after parathyroid- 
ectomy in dogs, which results in a change toward alkalinity. 

It is evident from the foregoing review of the literature that 
the evidence is conflicting and that it is impossible at present to 
draw any positive conclusions as to the etiology of spasmophilia. 
It seems almost certain, however, that the increased nervous 
irritability in this condition is due either to a diminution of the 
salts of calcium and magnesium in the tissues or to an excess of 
the salts of sodium and potassium. It seems more probable that 
it is due to a diminution of the salts of calcium and magnesium 
than to an increase in those of sodium and potassium. If it is 
due to a diminution in the salts of calcium and magnesium, it is 
possible that the diminution in these salts is connected in some 
way with a disturbance of the functions of the parathyroids. 

Treatment. — Clinically the symptoms of spasmophilia in in- 
fancy almost invariably disappear promptly when the babies are 
put on human milk. In the very rare instances in which they 
develop in babies that are on the breast, they are likely to dis- 
appear if the baby is given another breast-milk. If it is impossible 
to give breast-milk, the bowels should be thoroughly cleaned out, 
as this may perhaps do good by eliminating the salts of sodium 
and potassium. The food should be changed to one made up of 
carbohydrates. The basis of this food should be one of the cereal 

1 MacCallum and Voegtlein: Journ. Exp. Med., 1909, xi, 118. 

2 Howland and Marriott: Trans. Amer. Ped. Soc, 1916, xxviii, 200. 

3 MacCallum, Lambert and Vogel: Journ. Exp. Med., 1914, xx, 149. 

4 Wilson, Stearns and Thurlow: Journ. Biol. Chem., 1915, xxiii, 89 and 
Wilson, Stearns and Janney: Journ. Biol. Chem., 1915, xxi, 169 and 1915, 
xxiii, 123. 



TREATMENT 359 

waters to which any one of the disaccharides may be added. Whey 
is distinctly contraindicated, because of the large amount of salts 
which it contains. It is inadvisable to keep a baby on such a 
strictly carbohydrate diet more than a week at the outside and 
some form of milk must be added. The protein is best added in 
the form of precipitated casein and the fat in the form of high 
percentage creams, in order to avoid the salts in the whey. Modi- 
fied protein-milk is often useful. No artificial food can, however, 
take the place of human milk in this condition. Without it, re- 
covery is always slow and relapses frequent. 

Phosphorus and cod-liver oil are highly recommended by many 
authors because of the supposedly favorable influence of this 
combination in the retention of calcium and because of the prob- 
ability that spasmophilia is due to a lack of calcium in the tissues. 
The results reported by those who have used this method of treat- 
ment are, however, conflicting and there is considerable doubt, 
moreover, as to whether phosphorus and cod-liver oil really do 
increase the retention of calcium. (See page 338.) 

Calcium salts have also been used in the treatment of this con- 
dition on the ground that it is due to a lack of calcium in the tissues. 
Netter, Meyer, Zybell 1 and Sedgwick have obtained favorable 
results with them. Rosenstern 2 was able to reduce the electrical 
excitability temporarily by giving large amounts of calcium by 
mouth. Other observers have not been able to obtain such favor- 
able results. When it is impossible to get human milk, it is worth 
while, however, to try the calcium salts. The best form to use is 
dessicated calcium chloride. It should be given in doses of ten 
grains, six or seven times daily. 

Berend 3 has obtained favorable results by the use of subcutane- 
ous injections of anhydrous magnesium sulphate, which seems 
indicated an account of the probable disturbance of the calcium 
balance and because of its depressing effect on the nervous system. 
He used from 20 eg. to 40 eg. of an 8% solution per kilogram of 
body weight. 

Because of the diminution in the amount of the calcium salts in 
the tissues after parathyroidectomy and the probability that 
spasmophilia is due to a lack of calcium, it was suggested that the 
administration of parathyroids or of parathyroid extract by mouth 

1 Netter: Archiv. f. Kinderh., 1903, xxxv, 473; Meyer: Jahrb. f. Kinderh., 
1911, lxxiv, 560; Zybell: Muench. Med. Woch., 1911, lviii, 2357 and Jahrb. f. 
Kinderh., 1913, lxxviii, Supp. 29). 

2 Rosenstern: Jahrb. f. Kinderh., 1910, lxxii, 154. 

3 Berend: Monatschr. f. Kinderh., 1913-14, xii, 269. 



360 TREATMENT 

might be of service. Thus far no favorable results have been 
obtained in this way. Moreover, MacCallum and Vogel * found 
that the administration of parathyroids did not increase the cal- 
cium content of the blood. 

1 MacCallum and Vogel: Journ. Exp. Med. 1913, xviii, 618. 



CHAPTER XXX 
ACIDOSIS 

Acidosis is a symptom and not a disease. It is characterized 
by air hunger in which the normal abdominal type of respiration 
is replaced by one which is both costal and abdominal. There is 
a greater amplitude in the respirations which are made with a 
distinct effort. There is a diminished amount of alkali in the 
blood and a low carbon dioxide content in the alveolar air. There 
may or may not be acetonuria. Acidosis is one of the symptoms 
of "intestinal intoxication. " 

Reaction of the Blood. — The reaction of the blood is normally 
alkaline and is maintained at a remarkably constant level by a very 
delicate and complicated mechanism. The products of metabolism 
are acid and there is, therefore, a constant stream of acid poured 
into the blood, which must be carried to the organs of excretion to 
prevent its accumulation in the body. If these acids should ac- 
cumulate in sufficient quantity to change the reaction of the 
blood toward acidity, acidosis would result and if the accumulation 
of acid should become sufficiently concentrated, death would en- 
sue. The delicate mechanism regulating and maintaining the 
normal reaction of the blood is, therefore, one of the conspicuous 
factors of safety. The far reaching investigations of Henderson * 
and his co-workers on problems relating to the reaction of the 
body fluids have laid the foundation for our knowledge of acidosis. 

One of the end products of metabolism which is constantly flow- 
ing into the blood is carbonic acid. It is carried away from the 
cells by the tissue juices and blood in solution as sodium bicarbon- 
ate. In order that this may be accomplished, there must be 20 
parts of sodium bicarbonate in the blood for each part of carbonic 
acid which is being carried to the lungs. When it reaches the finer 
capillaries of the lungs, it is exposed to air, which has a lower carbon 
dioxide tension than that of the blood, and it diffuses from the blood 
into the air until the carbon dioxide tension of the blood is lowered 

1 Henderson: Am. Jour. Physiol., 1908, xxi, 427; Jour. Biol. Chem., 1911, ix, 
403; Henderson & Palmer; Jour. Biol. Chem., 1912-13, xiii, 393; 1913, xlv, 
81; 1914, xvii, 305; Yandell, Henderson & Haggard: Jour. Biol. Chem., 1918, 
xxxiii, 333. 

361 



362 ACIDOSIS 

to that of the air. It is excreted as carbon dioxide and water. The 
blood, then being relieved of its load of carbonic acid, passes again 
through the body picking up a new load to carry to the lungs. 
When an excess of carbonic acid is formed as a result of muscular 
exercise, the respiratory center is stimulated; the heart beats 
faster, and the acid is promptly carried to the lungs and eliminated. 
It is practically impossible to detect any accumulation of acid in 
the blood, owing to the nicety in which the delicate mechanism 
reacts to the slightest stimulus. The balance of acids and bases is 
kept practically unaltered except in extreme acidosis immediately 
preceding death. 

There are other acids resulting from the metabolism which 
must be excreted from the body, the most important of which 
are phosphoric acid and sulphuric acid. Phosphoric acid ordi- 
narily is carried in the blood by the dibasic phosphates. There 
must be 12.5 parts of dibasic phosphate for every part of phos- 
phoric acid carried. The combined acid and base are eliminated 
in the urine and during the process some base is lost from the body. 
This is quite different from the elimination of carbonic acid which 
is eliminated through the lungs without removing any base from 
the body. Since the bases are necessary for the maintenance of the 
acid-base equilibrium of the body, the bases which are excreted in 
the urine must be replaced, otherwise a diminished "alkali re- 
serve" would result with acidosis. A new supply of bases is ob- 
tained from the food, which supplies enough to replace those which 
are excreted in the urine. 

The bases are an essential part in the mechanism of carrying 
the acid end products of metabolism to the organs of secretion. 
The body can adapt itself to abnormal accumulations of acids 
either by increasing the ventilation of the lungs or by increasing the 
carbon dioxide capacity of the blood. The latter is apparently 
accomplished by drawing upon the "alkali reserve" and drawing 
alkali from the tissues into the blood. Acids may also combine 
with ammonia which can be derived from urea, a neutral substance. 
The ammonia in this case replaces some of the alkaline salts and 
allows the salts to combine with other acids. The presence of an in- 
creased amount of ammonia in the urine does not, in itself, indi- 
cate an acidosis but rather that the body is reacting to prevent 
acidosis. 

"So long as the eliminating mechanism for the excretion of 
acids is preserved, the "alkali reserve" is not affected, even 
though the production of "acids may be greatly increased. When 
acids are produced in excess or their elimination is interfered with, 



ACIDOSIS 363 

the normal preponderance of bases over acids is disturbed and 
acidosis results." 1 

Causes of Acidosis. — The far reaching investigations of How- 
land and Marriott, supplemented recently by those of Schloss have 
opened the field for the study of acidosis in infancy. Although 
much light has been thrown on the subject there yet remains much 
to be learned. The causes may be roughly grouped as follows: 

(1) Diarrhea in which there is an abnormal loss of alkali from 
the bowels and an insufficient intake in the food to make up for 
the loss. 

(2) Nephritis in which the kidney is incapable of excreting the 
acids normally found in the metabolism. There is not necessarily 
an excessive formation of acids but there always is a diminished 
power of elimination. 

(3) Perverted metabolism with excessive formation of normal 
or abnormal acids. This occurs especially in cases in which the 
metabolism of fat is abnormal, and results in the excretion of 
aceto-acetic acid and hydroxy butyric acid. These acids may be 
formed in large enough quantities to neutralize the blood alkali. 
There will then be too little base in the body to carry the other 
acids to the organs of excretion. 

Acetonuria. — The simplicity of the clinical tests for the acetone 
bodies in the urine, has led to their more general use in practice. 
Since the tests are often positive in many conditions which have no 
connection whatsoever with acidosis, there has been much confu- 
sion and loose use of the term acidosis. The sodium nitro-prusside 
test, 2 will detect minute quantities of acetone bodies in the urine, 
while the ferric chloride test 3 is less delicate and does not show the 
presence of acetone bodies in the urine unless they are present in 
considerable quantities. 

Acetone bodies may appear in the urine during starvation, with- 
out acidosis (see page 67), under normal conditions. They may 
also be present in the urine in many infections, without acidosis. 
Acetone bodies are found oftener in the urine of older children than 

1 Holt and Howland: Dis. of Infancy and Childhood, N. Y. & London, 1916, 
217. 

2 To one-sixth of a test tube of urine, add a crystal of sodium nitro-prusside 
and a few drops of glacial acetic acid. Shake, overlay with ammonium hy- 
drate. A purple color appears in the foam and at the line of juncture of the 
ammonia and urine, if acetone is present. 

3 A strong aqueous solution of ferric chloride is added to one-third of a test 
tube of urine. A Burgundy red color shows the presence of diacetic acid. If 
the reaction takes place after the urine has been previously boiled, it is not 
due to diacetic acid. 



364 ACIDOSIS 

infants. They are usually but not always present in acidosis. 
Acetonuria is frequently the precursor of acidosis, and is often con- 
fused with the symptom complex in which there is a diminished 
alkali reserve in the blood and a diminshed carbon dioxide ten- 
sion of the alveolar air. It is sometimes difficult to determine 
clinically when a case changes from a simple acetonuria to true 
acidosis. 

The carbon dioxide tension of the alveolar air, may be de- 
termined by the method described by Howland and Marriott. 1 
This method gives more evidence of value than does either of the 
tests for acetone bodies. It is simple and sufficiently accurate for 
all clinical purposes. Like all chemical methods, it requires prac- 
tice to obtain an efficient technique, the greatest care being taken 
to obtain a true sample of the alveolar air. The mistake of making 
too low readings is commoner than too high readings. If the di- 
rections given by Howland and Marriott are carried out exactly, 
duplicate readings should be obtained which will give an accurate 
estimate of the carbon dioxide elimination from the body. The 
normal carbon dioxide tension of the alveolar air in infancy is be- 
tween 37 and 45 mm. A lowered tension indicates acidosis. 2 A 
tension below 30 indicates a severe acidosis, and below 20 extreme 
acidosis. 

Van Slykehas especially emphasized the importance of measuring 
the carbon dioxide capacity or "alkali reserve" of the blood as an 
even more reliable index of acidosis than the carbon dioxide ten- 
sion of the alveolar air. Since it is difficult to obtain the necessary 
amounts of blood from sick infants, this test has not become a com- 
mon clinical procedure but has been used for scientific investi- 
gation. The Sellards test, the capacity of the body to absorb bi- 
carbonate of soda without turning the urine alkaline is also of 
value in estimating the " alkali reserve." The most important test 
in clinical practice, up to date, is the determination of the carbon 
dioxide tension of the alveolar air. 

Clinical Symptoms. — Acidosis in infancy is usually associated 
with vomiting and diarrhea, but it may be present without either of 
these symptoms. Drowsiness, when it occurs, is a later symptom. 
There is usually an odor of acetone on the breath, and chemical 
tests show the presence of acetone bodies in the urine. The first 
symptom of importance is an increase in the depth of respiration 
which soon becomes air hunger. This is due to the increased car- 
bon dioxide in the blood which stimulates the respiratory center 

1 Howland and Marriott: Am. Jour. Dis. Children, 1916, xi, 309. 

2 Howland and Marriott: Bull. Johns Hopkins Hosp., 1916, xxvii, 63. 



ACIDOSIS 365 

with the purpose of increasing the pulmonary ventilation. "The 
increased pulmonary ventilation may go on uninterrupted for 
hours. Eventually, in fatal cases, the respirations become fee- 
bler and feebler with only occasional deep gasps, and finally they 
cease altogether." 1 Instead of being cyanotic, the color of the lips 
is often bright red. There is frequently evidence of great loss of 
fluid from the body, depending on the severity of the vomiting and 
the diarrhea. The temperature may be slightly elevated or high 
according to the underlying disease. 

Schloss 2 showed that the phenolsulphonephthalein elimination 
of the kidneys and the water elimination are greatly diminished. 
It has long been known that albumen and casts are present in the 
urine of infants affected with severe diarrhea; the degree of albu- 
minuria, however, is rarely great. Both of these facts indicate 
that the kidney is not functioning normally. 

Acidosis may complicate infectious diarrhea, "intestinal intox- 
ication/' pneumonia, nephritis, cyclic vomiting, and severe res- 
piratory infections. It may be mistaken for the onset of menin- 
gitis acute surgical conditions in the abdomen, general septicaemia, 
and pneumonia. 

Pathology. — There are no outstanding features in the pathology 
of acidosis. According to Lacker and Gauss 3 there is lipemia from 
failure of the body tissues to utilize the fat in the blood and, as a 
result, lipuria. They also find fatty infiltration of the liver and 
fatty degeneration of the kidneys. Lesions in the kidneys are by 
no means the rule, as they were absent in five of the eight cases 
reported by Schloss. The intestinal mucosa is sometimes con- 
gested, but as a rule is pale and somewhat atrophic. Small ero- 
sions of the duodenal mucosa occur in some cases. 

Prognosis. — The prognosis depends both on the underlying 
disease and the treatment. Cases with acetonuria only, practi- 
cally always recover. When the stage of air hunger is reached with 
a diminished carbon dioxide tension of the alveolar air, the prog- 
nosis is influenced a great deal by the treatment. The lower the 
carbon dioxide tension of the alveolar air, the graver the prog- 
nosis. When the tension is below 20 the prognosis is grave even 
with energetic and appropriate treatment. 

Treatment. — The treatment depends upon the clinical appear- 
ance of the patient and upon the chemical findings. If the disease 
commences with digestive symptoms and there is evidence of fer- 

1 Howland and Marriott: loc. cit. 

2 Schloss: Am. Jour. Dis. Children, 1918, xv, 165. 

3 Lacker and Gauss: Am. Jour. Dis. Children, 1917, xiii, 209. 



366 ACIDOSIS 

mentation or putrif action in the lower bowel, a cathartic should be 
given to remove the accumulation of fecal material and gas. Cas- 
tor oil, which works more rapidly than the other cathartics com- 
monly used, should be given in doses varying from two teaspoons 
to one tablespoon according to the age of the infant. Since castor 
oil is often vomited, calomel 1/10 grain every one half hour for ten 
doses, followed by a teaspoon of milk of magnesia, may be given 
to those infants in which vomiting is a prominent symptom. 
Calomel should not be repeated in less than three days because it 
is in itself an irritant. After the retained fecal material and gas 
has been cleared out of the bowels, a severe watery diarrhoea with- 
out gas may commence. Physical examination shows a scaphoid 
abdomen. At this stage cathartics are contra-indicated because 
the bowels are emptying themselves very rapidly, and because 
much fluid and salts are being drawn from the body in the liquid 
stools. This, if long continued, will result in lowering the "alkali 
reserve" in the blood, and cause true acidosis. The loss of liquid 
and alkali from the body should, therefore, be stopped as recom- 
mended by Howland and Marriott 1 Paregoric should be given in 
doses of from two to four minims after each movement of the 
bowels, the dose varying with the age of the infant. Such dosing 
regulates itself with the severity of the diarrhea, and may be 
omitted when the number of stools have been reduced to three a 
day. 

The most important single factor in the treatment of acidosis, 
is to maintain the body fluid. This can not be done intelligently 
unless a written record is kept of every ounce of fluid taken and 
retained by the patient. It is also very helpful, if the nurse can 
measure or estimate the amount of fluid lost in the urine and 
stools. This, however, is usually impossible in young infants. On 
physical examination an idea may be obtained of the state of the 
fluids of the body by examining the fontanelle, (depressed fon- 
tanelle means loss of fluid), the skin (dry skin means a dried out 
body), and tongue (a red glairy dry tongue and mucus mem- 
brane means the same). Treatment should be instituted to first 
prevent drying out of the body and secondly to replace the body 
fluid that has already been lost. The technique of administering 
fluid varies with the individual case. When possible water should 
be given by mouth. Small amounts of liquid are usually retained 
when larger amounts are vomited. Liquids should be first given 
in teaspoon doses every five minutes throughout the twenty-four 
hours while the infant is awake. This is usually easy where there 
1 Howland & Marriott: Trans. Am. Ped. Soc, 1915, xxvii, 200. 



ACIDOSIS 367 

is intense thirst and restlessness. The amount and the intervals 
are increased when warranted by the clinical symptoms. Usually 
the dose is increased when the child goes two or three hours with- 
out vomiting. 

If water is not retained by mouth, it should be introduced by 
rectum. Since only small amounts can be introduced by enema 
at a time, it is best given by the Murphy drip method. A very 
good way is to allow the water to run in for two to three hours 
and then rest the bowel for an equal period of time before intro- 
ducing the catheter again. This often makes it possible to con- 
tinue the administration of liquids through the bowels over a longer 
period of time than if the tube were allowed to remain in continu- 
ously. If diarrhea is present the tube will not be retained except 
when carefully and skillfully handled. Since it is essential that liq- 
uid be introduced into the body, in cases where it is not retained 
by either the stomach or rectum it must be introduced in other 
ways. 

Subcutaneous or intravenous infusion of liquid are the last re- 
sorts and in severe cases should be used immediately. Three to six 
ounces of liquid may be introduced subpectorally, or by intraven- 
ous injection. Intravenous injections of liquid are very difficult in 
infancy owing to the small size of the veins. The best results 
have been obtained by putting it directly into the lateral sinus. 

Type of Liquids to be Used. — Very often the stomach can retain 
water only. If there is air hunger or a lowered carbon dioxide 
tension of the alveolar air 75 to 150 c. c. of 4% bicarbonate of 
soda solution must be introduced into the body subcutaneously or 
intravenously. If it is used subcutaneously or intravenously, it 
should be sterile. Care should be taken that none of the bicar- 
bonate of soda has changed into sodium carbonate which is irri- 
tating and may cause a slough. (Directions for the preparation of 
the sterile bicarbonate solutions are given in the paper by How- 
land.) The intravenous treatment should not be persisted in after 
the urine becomes alkaline. 

Sugars may also be introduced into the body. There are two 
reasons why this should be done. First: during starvation (per- 
sistent vomiting is starvation) sugar is quickly used up in supply- 
ing the body with fuel to make the energy necessary for life. 
Secondly it prevents the formation of the acetone bodies and thus 
tends to prevent acidosis. Orange juice may be given in small 
amounts by mouth. The young infants may be given 5% solution 
of milk sugar, or cane sugar. Sugar solutions may be given by 
rectum, subcutaneously or intravenously according to the ex- 



368 ACIDOSIS 

igencies of the case. When given by rectum it may be given in a 
5 to 10% solution : when given under the skin or into a vein, it 
should contain 5% or less. The best sugar to employ under these 
circumstances is chemically pure glucose (dextrose) which is the 
same sugar normally present in the blood and requires no diges- 
tion before it can be used. Corn syrup (Karo), is a cheap and 
satisfactory form of glucose to use in rectal enemata. It is not 
pure enough to inject directly into the blood. 

Food. — As has been stated above, a sufficient amount of liquid 
to carry the waste products of the body through the kidneys in a 
sufficiently diluted form as not to damage the kidneys is one of the 
essentials of the successful treatment of acidosis. The food, how- 
ever, may be regulated in such a manner as to lessen the burden 
of the body. Since acetone bodies are formed primarily from fat, 
fat should be excluded from the food when given. Sugars should 
be given when possible to prevent the formation of acetone bodies. 
Since the starches are converted by the digestion into sugar they 
may be given in the form of barley water or some cereal concoction 
and in older infants in the form of barley jelly. Although pro- 
teins may take part in the formation of acetone bodies, they do not 
seem to do so in sufficient amounts to be of any clinical importance. 



INDEX OF NAMES 



Adriance, on chemistry of colostrum, 

104 
Albertoni, on purgative action of 

sugars, 38 
Albu-Neuberg, on mineral metab- 
olism, 58 
Alwens and Husler, on shape of 

stomach, 4 
Allaria, on reaction of mouth, 3 
Allen, on intoxicating action of 

sugars, 41 
Arndt, on calcium retention, 336 
Aron and Sebauer, on experimental 

rickets, 332 
Aschenheim, on mineral salts in 

spasmophilia, 356 
Aschner and Grigori, on galacta- 

gogues, 125 
Ayers and Johnson, on pasteurized 

milk, 182 

Babcock, on nitrogenous compounds 

of milk, 166 
Bahrdt, on absorption of fat, 25, 26; 

on infantile atrophy, 29 
Bahrdt and Bamberg, on acidity of 

stools, 37 
Bahrdt and Beifeld, on bacteriology 

of intestines, 83 
Bahrdt and Edelstein, on chemistry 

of scurvy, 348; on fatty acids in 

milk, 159; on iron in human milk, 

121 
Bahrdt and McLean, on acidity of 

stools, 37 
Baker, on intracutaneous test for 

dysentery bacillus, 306 
Bartenstein, on experimental scurvy, 

345 
Basch, on influence of ovary on 

breast, 126; on placental extract, 

125 
Bauer, on differentiation of human 

milk, 129; on protein of colostrum, 

106 



Baumann and Howard, on me- 
tabolism in scurvy, 348 

Bayliss and Starling, on secretion, 
15,44 

Beck, on caloric requirements, 73 

Behring, on alexins, 181 

Bendix, on menstruation and lacta- 
tion, 128 

Benedict and Talbot, on body surface 
and metabolism, 67; on body 
weight and metabolism, 68; on 
effect of exercise on metabolism, 
66; on fasting metabolism, 67; on 
gaseous metabolism, 64 

Benjamin, on casein curds, 49 

Berend, on treatment of hemophilia, 
359 

Bergell and Langstein, on analysis of 
casein, 114 

Berger, on alimentary anaphylaxis, 
51; on salivary glands, 1 

Bergmann, on body surface and 
metabolism, 67 

Bergmark, on alimentary glycemia, 36 

Bessau, on bacteriology of gastro- 
intestinal canal, 77 

Biedert, on casein curds, 46; on fat 
diarrhea, 27 

Bienenfeld, on coagulation of human 
milk, 110 

Birk, on mineral metabolism, 61; 
on phosphorus in rickets, 339 

Blauberg, on phosphorus metabolism, 
60 

Block, on exclusive carbohydrate 
diet, 38 

Bloor, on absorption of fat, 21, 22 

Bolle, on experimental scurvy, 345 

Bonnoit, on gaseous metabolism, 64 

Bordet, on specificity of proteins of 
milk, 115 

Bosworth, on action of sodium cit- 
rate, 12 

Bosworth and Van Slyke, on casein, 
163 



370 



INDEX OF NAMES 



Bowditch, on calculating caloric 

values, 240 
Bowditch and Bosworth, on dried 

casein, 224 
Brennemann, on casein curds, 49; 

on rennin coagulation of boiled 

milk, 216 
Brown and Fletcher, on spasmophilia, 

354, 356 
von Brunning, on digestibility of 

heated milk, 183 
Buchholz, on colostrum corpuscles, 

105 
Bundin, on caloric requirements, 73 

Caldwell, on breast pumps, 141 

Camerer and Soldner, on calcium 
metabolism, 332; on chemistry of 
colostrum, 104; on protein of hu- 
man milk, 111 

Cannon, on absorption in stomach, 
14; on duration of gastric digestion, 
6; en function of stomach, 8 

Carel, on scurvy and heated milk, 
184, 344 

Carlson and Ginsberg, on gastric 
hunger, 7 

Carpenter and Murlin, on energy 
metabolism in pregnancy, 65 

Cathcart, on protein synthesis, 38 

Chapin, on caloric value of food, 199 

Chapin and Pisek, on fat percentage 
in bottled milk, 230 

Chatin and Rendu, on milk as galac- 
tagogue, 126 

Ciccarelli, on proteins of human 
milk, 114 

Clark, on action of lime water, 12; 
on reaction of human milk, 108 

Cobliner, on pyrogenic effect of 
sodium halogens, 40 

Cohnheim, on antitrypsin, 44; on 
erepsin, 45 

Courant, on coagulation of milk by 
rennin, 163 

Courtney, on absorption of fat, 26; 
on casein curds, 48; on mineral 
metabolism, 62; on nitrogen re- 
tention, 54 

Cowie, on alkalies in pyloric spasm, 
257 

Cowie and Lyon, on pyloric reflex, 8 

Cramer, on caloric requirements, 72; 



on influence of ovary on breast, 
126; on quantity of milk secretion, 
108 

Cronheim and Muller, on calcium re- 
tention, 336; on nitrogen excretion, 
52 

Czerny, on colostrum, 103; on colos- 
trum corpuscles, 105; on exudative 
diathesis, 31 

Czerny and Keller, on absorption of 
fat, 25; on caloric requirements, 73 
on chemistry of human milk, 103 
on feeding of premature infant, 251 
on influence of food on human 
milk, 124 

Czerny and Steinitz, on metabolism 
in digestive disturbances, 55 

Davis, on mortalitv of artificially- 
fed, 99 

Debele, on length of intestines, 18 

De Jager, on digestibility of heated 
milk, 183 

De Just and Constant, on starch in 
stools, 95 

Demme, on fat diarrhea, 27 

Dennett, on caloric requirements, 73 

Deville, on colostrum corpuscles, 106 

Dibbelt, on calcium in human milk, 
333 

Dluski, on "running in" of human 
milk, 134; on statistics of breast 
feeding, 100 

Dodd, on experimental scurvy, 347 

Dundin, on reaction of stomach, 11 

Ehrlich, on transmission of immunity 
through milk, 132 

Engel, on coagulation of human 
milk, 110; on fat in human milk, 
116: on gastric secretions, 10; on 
protein in human milk, 113 

Engling, on composition of cow's 
milk, 157 

Erdheim, on parathyroids in spas- 
mophilia, 357 

Escherich, on bacteriology of stom- 
ach, 78; on bacteriology of stools, 
85; on casein curds, 46; on en- 
dogenous intestinal infection, 80; 
on intoxicating effect of sugars, 41 

Feer, on amount of milk at nursing, 
109; on caloric requirements, 72 



INDEX OF NAMES 



371 



Ficker, on bacteriology of intestine, 

80 
Fife and Veeder, on infantile atrophy, 

29, 55 
Finizio, on fat in stools, 31; on pro- 
tein of human milk, 128; on 

salivary amylolysis, 3 
Finkelstein, on caloric requirements, 

73; on effects of heated milk, 184; 

on etiology of digestive disturb- 
ances, 39, 40 
Finkelstein and Meyer, on intestinal 

fermentation, 40, 222 
Fisher and Moore, on absorption of 

sugars, 39 
Fleischmann, on digestibility of 

heated milk, 183 
Fliigge, on bacteria of milk, 181 
Folin and Denis, on absorption of 

amino acids, 46 
Folin and Wentworth, on fat me- 
tabolism, 24 
Ford and Blackfan, on bacteriology 

of intestines, 83 
Forster, on gaseous metabolism, 64 
Fraley, on calculating caloric values, 

240 
Freeman, on ferments in milk, 130 
Froise, on antiscorbutics, 353 
Freund, on absorption of fat, 25; 

on chlorides of human milk, 121; 

on fat in calcium metabolism, 335; 

on infantile atrophy, 29 
Friberger, on pyrogenic effect of 

sodium halogens. 40 
Frolich, on experimental scurvy, 345 
Funk, on vitamins, 349 
Furst, on experimental scurvy, 345, 

347 

Gamble, on nitrogen excretion, 56; 

on spasmophilia, 354 
Gaus, .on caloric requirements, 72 
Gavin, on pituitary extract, 125 
Gephart and Czonka, on fat metab- 
olism, 24 
Geptner, on composition of bile, 17 
Gittings, on caloric requirements, 

73 
Grosz, on excretion of sugars, 38 
Grulee, on spasmophilia, 354, 357 
Grulee and Caldwell, on menstrua- 
tion and lactation, 128 



Gundobin, on absorption in stomach, 
14; on pancreatic ferments, 15 

Haberfeld, on parathyroids in spas- 
mophilia, 357 

Hahn, on alimentary anaphylaxis, 51 ; 
on gastric acidity, 12; on rennin, 13 

Hallion and Lequeux, on secretion, 
45 

Hamburger, on alimentary anaphy- 
laxis, 50 

Hamburger and Sperk, on hydro- 
chloric acid, 11 

Hammarsten, on coagulation of milk 
by rennin, 162 

Hammett and McNeille, on placental 
extract, 125 

Hammond, on galactagogues, 125 

Hart, on experimental scurvy, 347 

Hartge, on size of pancreas, 14, 15 

Hayaslei, on infantile atrophy, 29 

Hecht, on digestion of fat, 30; on 
infantile atrophy, 29, 30; on 
trypsin in stools, 44 

Hedenius, on carbohydrates in stools, 
36 

Hedon, on purgative action of sugars, 
38 

Helmholtz, on pyrogenic effect of 
sodium halogens, 40 

Henderson, on acidosis, 361 

Herter and Kendall, on bacteriology 
of intestines, 84 

Hess, on amylolytic ferments, 34; 
on antiscorbutics, 352; on bac- 
teriology of duodenum, 79, 80; 
on gastric lipase, 10; on hydro- 
chloric acid, 11; on lipase, 15; on 
scurvy as deficiency disease, 350 

Hess and Fish, on blood in scurvy, 342 

Heubner, on caloric requirements, 72; 
on caloric value of milk, 177; on 
energy quotient, 71; on lactic acid 
in stomach, 10 

Heubner and Lippschultz, on ex- 
perimental scurvy, 347 

Hippius, on composition of boiled 
milk, 181 

Hoist and Frolich, on experimental 
scurvy, 345 

Holt, on excretion of salts in diarrhea, 
62; on gastric capacity, 5; on in- 
fantile atrophy, 28; on statistics 



372 



INDEX OF NAMES 



of breast feeding, 100; on utiliza- 
tion of salts, 59 

Holt, Courtney and Fales, on ash of 
human milk, 120 

Holt and Levene, on casein, 50 

Hoobler, on effect of diet on human 
milk, 124; on effect of diet on pro- 
teins of milk, 148; on magnesium 
metabolism, 60; on mineral me- 
tabolism, 58; on protein need, 56 
on utilization of salts, 59 

Howland, on alimentary anaphylaxis, 
50; on carbohydrates in calcium 
metabolism, 335; on casein curds, 
48; on exercise and metabolism, 66; 
on fasting metabolism, 66; on 
gaseous metabolism, 65; on min- 
eral metabolism, 61; on output of 
heat, 66; on thymus and rickets, 
331 ; on tolerance of fat, 31 

Howland and Marriott, on acidosis 
in diarrhea, 62; on calcium me- 
tabolism in spasmophilia, 355; on 
carbon dioxide tension of alveolar 
air, 364 

Ibrahim, on amylolytic ferments of 
pancreas, 32; on amylolytic fer- 
ments of stomach, 32; on casein 
curds, 49; on diastase of saliva, 
2, 32; on enterokinase, 16, 44; on 
lactase of intestine, 33; on trypsin, 
44 

Ibrahim and Gross, on secretin, 44 

Jackson and Moody, on infectious 

nature of scurvy, 343 
Jackson and Moore, on experimental 

scurvy, 350; on inanition and 

ncurvy, 347 
Janney, on protein synthesis, 38 
Jappelii, on absorption of sugars, 39 
Jemma, on digestibility of heated 

milk, 183 
Jensen, on composition of cow's milk, 

166 
Jordan and Harris, on bacillus lac- 

timorbi, 177 
Judell, on excretion of salts in di- 
arrhea, 62 

Kassowita, on pathology of rickets, 
331; on phosphorus in rickets, 339 



Kastle, on coagulation of milk, 159 

Kastle and Loevenhart, on lipase, 21 

Kastle and Porch, on ferments of 
milk, 181 

Kastle and Roberts, on composition 
of boiled milk, 180 

Katzenellenbogen, on calcium me- 
tabolism in spasmophilia, 355 

Keefe, on .pyloroplasty in pyloric 
stenosis, 266 

Keller, on carbohydrates in protein 
digestion, 37; on nitrogen excretion 
in starvation, 52; on phosphorus 
in human milk, 122 

Kendall, on bacteriology of intestine, 
82; on gas bacillus in infectious 
diarrhea, 303 

Kendall and Farmer, on protein- 
sparing action of carbohydrates, 37 

Kissel, on phosphorus in rickets, 339 

Klose, on relation of oedema to salts, 
62 

Klotz, on bacteriology of stools, 85; 
on digestion of starch, 212 

Knopfelmacher, on casein curds, 47 

Knox and Ford, on gas bacillus in 
intestines, 86 

Knox and Tracy, on phosphorus 
metabolism, 61 

Kocher, on protein-sparing action of 
lactic acid, 38 

Koeppe, on chemistry of milk, 170 

Konig, on chemistry of colostrum, 
104; on composition of goat's milk, 
174 

Koplik, on statistics of breast feed- 
ing, 100 

Koplik and Crohn, on infantile 
atrophy, 30 

Kowalski, on liver, 16 

Kramsztyk, on bacteriology of stools, 
85; on gastric trypsin, 10 

Krasnagorski, on digestibility of 
heated milk, 184; on iron metab- 
olism, 60 

Kumagawa and Suto, on fat metab- 
olism, 24 

Lacker and Gauss, on lipemia in 

acidosis, 365 
Ladd, on caloric requirements, 73; 

on duration of gastric digestion, 6 
Lane-Claypon, on digestibility of 



INDEX OF NAMES 



373 



heated milk, 183; on scurvy and 

heated milk, 344 
Lang and Fenger, on reaction of 

intestines, 18 
Langendorff, on pepsin, 43 
Langlois, on gaseous metabolism, 64 
Langstein and Edelstein on phos- 
phorus of human milk, 115 
Langstein and Steinitz, on excretion 

of sugars, 39; on lactase of diseased 

intestine, 34 
Langworthy and Holmes, on digest- 
ibility of fat, 21 
Lawrence, on typhoid bacilli in 

breast milk, 107 
Laws and Bloor, on estimating fat 

in stools, 96 
Leach, on composition of cow's milk, 

165 
Leopold and Reuss, on pyrogenic 

effect of sugars, 40 
Leschziner, on bacteriology of stools, 

85 
Liebig, on mineral metabolism, 58 
Litzenberg, on feeding premature 

infant, 251 
Liwschiz, on casein curds, 48 
Logan, on bacillus bifidus, 84; on 

virulence of bacillus coli, 80 
London, on absorption of amino 

acids, 46 
Luling, on infant mortality, 99 
Lusk, on growth promoting proteins, 

57 
Lusk and Klocman, on metabolism 

in scurvy, 348 
Lust, on alimentary anaphylaxis, 51; 

on antiproteolytic ferment of blood, 

45; on sodium chloride retention in 

spasmophilia, 356 

MacCallum and Voegtlin, on cal- 
cium metabolism in spasmophilia, 
355 

McCollum and Davis, on vitamins, 
56, 350 

McCollum and Kennedy, on vita- 
mins, 350 

McCollum and Pitz, on experimental 
scurvy, 350; on infectious nature of 
scurvy, 343 

MacKenzie, on galactagogues, 125 

Mai, on freezing of milk, 171 



Major, on shape of stomach, 4 

Marfan, on ferments of milk, 186 

Marriott, on intoxicating effect of 
sugars, 42 

Martin, on statistics of breast feeding, 
101 

Matti, on internal secretions in 
rickets, 331 

Mayerhofer and Roth, on caloric re- 
quirements, 73 

Meigs and Marsh, on identified sub- 
stances in human milk, 122 

Mellanby, on etiology of diarrhea, 49 

Mendel and Keliner, on excretion of 
sugars, 39 

Mettenheimer, on internal secretions 
in rickets, 331 

Meyer, A. H., on duration of gastric 
digestion, 6; on lactic acid in 
stomach, 10 

Meyer, L. F., on infantile atrophy, 29; 
on mineral metabolism, 58, 61, 62; 
on tolerance of fat, 31 

Mitra, on gastric ferments, 45 

Michael, on digestibility of heated 
milk, 183 

Miura, on invertin of intestine, 33 

Miura and Stoeltzner, on pseudo- 
rachitic osteoporosis, 331 

Modigliani and Benini, on alimentary 
anaphylaxis, 51 

Monrad, on casein, 50 

Moore and Jackson, on experimental 
scurvy, 345 

Moro, on amylolytic ferments of 
pancreas, 32; on bacteriology of 
intestine, 80; on carbohydrate 
digestion in newborn, 34; on dif- 
ferentiation of human milk, 128; 
on dyspepsia in breast-fed, 107; 
on endogenous intestinal infection, 
80 

Moro and Bauer, on anaphylaxis in 
marasmus, 50 

Morse, on casein, 50 

Mosenthal, on gastric capacity, 5 

Miiller, Ed., on proteolytic ferment 
of saliva, 43 

Muller, Fr., on casein curds, 46 

Miiller and Cronheim, on digestibility 
of heated milk, 184 

Murlin and Hoobler, on body sur- 
face and metabolism, 67; on exer- 



374 



INDEX OF NAMES 



cise and metabolism, 66; on gaseous 
metabolism, 65 

Nagao, on digestion of starch, 212 
Niemann, on alimentary glycemia, 36 
NobScourt and Merklen, on absorp- 
tion of fat, 25 
Noguchi, on mutation of bac. bifidus, 

84 
Noll, on absorption of fat, 22 
Nordheim, on statistics of breast 

feeding, 100 
Nothmann, on lactase of intestine, 
34; on pyrogenic effect of sodium 
halogens, 40 

Ohlmuller, on infantile atrophy, 28 

Oppenheimer, on caloric require- 
ments, 73 

Orban, on lactase of diseased in- 
testine, 34 

Orgler, on chemistry of rickets, 334; 
on fat in calcium metabolism, 335; 
on nitrogen metabolism, 53 

Osborne and Guest, on chemistry of 
casein, 167 

Oshima, on reaction of mouth, 1 

Palmer and Eckles, on pigments of 
human milk, 117; on pigments of 
milk fat, 169 
Passini, on peptonizing bacillus, 82 
Pechstein, on gastric ferments, 43 
Pennington, on freezing of milk, 171 
Pfannenstill, on absorption in stom- 
ach, 14 
Pfaundler, on gastric capacity, 4 
Pfaundler and Schlossmann, on chem- 
istry of boiled milk, 179; on di- 
gestibility of heated milk, 183 
Pfeiffer, on chemistry of colostrum, 

104 
Pisek and Lewald, on duration of 
gastric digestion, 6; on shape of 
stomach, 4 
Plantenza, on scurvy and heated 

milk, 185, 345 
Porter and Dunn, on tolerance of 

lactose, 41 
Pottevin, on ferments of meconium, 33 

Quest, on calcium metabolism in 
spasmophilia, 355 



Raczynski, on acidity of stools, 37 

Rammstedt operation, 266 

Raudnitz, on chemistry of casein, 167; 
on digestibility of heated milk, 183 

Reiss, on action of mineral salts, 356 

Renton and Robertson, on thymus 
and rickets, 331 

Rettger, on bacteriology of intestines, 
84, 297 

Reuss, on infantile atrophy, 30 

Reye, on spasmophilia, 354 

Richet, on gaseous metabolism, 64 

Richmond, on acidity of milk, 160; 
on composition of cow's milk, 166 

Riesel, on calcium metabolism in 
spasmophilia, 355 

Robertson, on precipitation of casein, 
161 

Rodella, on peptonizing bacillus, 82 

Rohmann, on amylolysis, 35 

Rohmann and Nagano, on absorp- 
tion of sugars, 38 

Romer, on transmission of agglutinins 
through milk, 133 

Rosenau, on bacteria of milk, 181; % 
on composition of boiled milk, 
180; on digestibility of heated 
milk, 183 

Rosenfeld, on fat metabolism, 24 

Rosenstern, on mineral salts in spas- 
mophilia, 356 

Rosenthal, on pyrogenic effect of 
sugars, 40 

Rossi, on effect of saliva on pep- 
tolysis, 45 

Rotch, on menstruation and lacta- 
tion, 127 

Rothberg, on mineral metabolism, 61 

Rubner, on body surface and metab- 
olism, 67; on caloric values, 71 

Rubner and Heubner, on gaseous 
metabolism, 64 

Samelson, on fat-splitting ferments, 

22 
Schabad, on chemistry of rickets, 334; 

on skeletal weight of newborn, 332; 

on treatment of rickets, 339 
Schafer and MacKenzie, on galacta- 

gogues, 125 
Schaps, on pyrogenic effect of sugars, 

40 
Schloss, on alimentary anaphylaxis, 



INDEX OF NAMES 



375 



51; on cod-liver oil in rickets, 338; 
on excretion in acidosis, 365; on 
intestinal intoxication, 50; on pyro- 
genic effect of sodium halogens, 40 

Schlossmann, on caloric requirements, 
72; on casein, 167; on casein of 
human milk, 114; on nitrogen of 
human milk, 112; on phosphorus 
of human milk, 122; on preserva- 
tion of human milk, 156 

Schlossmann and Murschhauser, on 
fasting metabolism, 53, 66; on 
gaseous metabolism, 64; on metab- 
olism during starvation, 75 

Schlutz, on pyrogenic effect of so- 
dium salts, 41 

Schorer and Rosenau, on pasteuriza- 
tion of milk, 187 

Schwarz, on protein utilization, 55 

Sedgwick, on gastric lipase, 10 

Selter, on casein curds, 47; on ken- 
otoxine, 49 

Shaw, on salivary diastase, 2 

Shaw and Gilday, an absorption of 
fat, 25 

Sherman, on casein, 167 

Siegert, on caloric requirements, 72; 
on heredity in rickets, 330 

Sikes, on phosphorus in human milk, 
122 

Sill, on effects of pasteurized milk, 
184 

Sisson, on bacteriology of intestines, 
83, 297 

Sittler, on bacteriology of intestines, 
83 

Skvortzov, on fat in human milk, 117 

Smith, Theobald, on duality of 
tubercle bacillus, 176 

Sttldner, on ash of human milk, 58, 
120; on ash of newborn, 58 

Solomin, on composition of boiled 
milk, 180 

Sommerfeld, on boiled milk, 179; 
on bacteria of milk, 181 

Sonnenberger, on transmission of 
toxins through milk, 132 

Southworth, on action of alkalies, 12 

Spolverini, on ferments in milk, 129 

Steinitz, on infantile atrophy, 28; 
on mineral metabolism, 61 

Steinitz and Weigert, on fat metab- 
olism, 31 



Stoeltzner, on calcium metabolism in 

spasmophilia, 355 
Strassburger, on bacteriology of 

stools, 85 

Talbot, on caloric requirements, 72; 

on casein curds, 46; on mesenteric 

tuberculosis, 30; on reaction of 

fatty stools, 27 
Talbot and Gamble, on metabolism 

during protein indigestion, 55 
Talbot and Hill, on absorption of fat, 

26; on acidity of stools, 37; on 

utilization of salts, 59 
Talbot and Peterson, on experimental 

scurvy, 345 
Ten Broeck, on dysentery bacillus 

in diarrhea, 86 
Thiemich, on uremia and lactation, 

128 
Thiemich and Mann, on typical law 

of contraction, 354. 
Tiemann, on colostrum, 103 
Tissier, on bacillus perfringens, 

292 
Tobler, on butyric acid, 79; on gas- 
tric digestion, 8; on fats in pyloric 

spasm, 20 
Tobler and Bessau, on mineral metab- 
olism, 58 
Tobler and Bogen, on duration of 

gastric digestion, 7 
Tobler and Noll, on rickets, 333 
Towle and Talbot, on eczema and 

fat, 31 
Towles, Caroline, on phosphorus 

cod-liver oil in rickets, 340 
Tugendreich, on differentiation of 

human milk, 129 

Uffelmann, on absorption of fat, 25; 

on casein curds, 46; on excretion of 

fat, 26, 27 
Uffenheimer and Takeno, on casein 

curds, 48 
Usuki, on absorption of fat, 26 

Van Slyke, on alkali reserve of blood, 
364; on nitrogenous bodies of milk, 
166; on precipitation of casein, 
161 

Van Slyke and Bosworth, on casein, 
162, 229 



376 



INDEX OF NAMES 



Van Slyke and Meyer, on absorption 

of amino acids, 46 
Variot, on scurvy and heated milk, 

184, 344 
Variot and Lavaille, on gaseous 

metabolism, 64 
Variot and Saint-Albin, on gaseous 

metabolism, 64 
Vaughan, on alimentary anaphylaxis, 

51 

Wakabayashi and Wohlgemuth, on 

intestinal ferments, 45 
Wassermann, on specificity of pro- 
teins of milk, 115 
Wegscheider, on casein curds, 46 
Weiss, on gaseous metabolism, 64 
Wentworth, on infantile atrophy, 29, 

30; on secretin, 45 
Wernstedt, on casein curds, 48 



Westcott, on calculation of formula 

for modified milk, 232 
Whitehead, on absorption of fat, 22 
Wienland, on intestinal antifermen- 

tos, 44 
Wilson, on absorption of fat, 22 
Wohlgemuth, on pancreatic secre- 
tions, 52 
Wolf, on milk as galactagogue, 126 
Wroblewski, on analysis of casein, 
114; on opalisin, 114 

Yanase, on parathyroids in spasmo- 
philia, 357 

Zuntz, on calorific value of oxygen, 65 
Zweifel, on diastase of saliva, 32; 

on pepsin, 43 
Zybell, on mineral salts in spasmo- 
philia, 356 



INDEX OF SUBJECTS 



Abortion, contagious, 177 

Acetonuria, 361, 363 

Acidosis, 50, 361; blood in, 361; 
etiology of, 363; in fat indigestion, 
273; pathology of, 363 

Actinomyces in cow's milk, 177 

Adenoids, interference with nursing, 
140 

Adrenalin, 316 

Agglutinins in human milk, 133 

Albumin milk in artificial feeding, 
218, 222 

Alcohol, excretion in human milk, 127 

Alexins of cow's milk, 181 

Alimentary decomposition (see In- 
fantile atrophy) 

Alkalies, action of, in digestion, 12; 
in artificial feeding, 216; effect on 
rennin, 163; in pyloric spasm, 
257 

Amino acids, 46, 57, 363 

Amylase in milk, 130 

Amylolysis, 35 

Amylopsin, 14 

Anaphylaxis, 50; to cow's milk, 194; 
differentiation of proteins by, 115; 
transmission through milk, 133 

Anemia, constipation in, 324 

Anthrax bacillus in cow's milk, 177 

Antibodies in human milk, 132 

Antiferments in blood, 45; in intes- 
tines, 44 

Anti-rennin, 165 

Antiscorbutics, 346, 352 

Antiseptics, intestinal, 296, 312, 313 

Antitoxin in human milk, 132 

Anus, fissure of, 322 

Ash (see Mineral salts) 

Avitaminoses, 349 

Babcock test, 229 

Bacteria, bacillus acidophilus, 292, 
296; bacillus bulgaricus, 296; bacil- 
lus coli, 175, 292, 302; bacillus per- 
fringens, 292; bacillus putrificus, 



292; bacillus pyocyaneus, 302; 
butyric acid bacilli, 79, 292, 297; 
in cow's milk, 175; dysentery 
bacillus, 302, 306, 309; gas bacillus, 
86, 296, 302, 305, 310; of gastro- 
intestinal tract, 77; lactic acid 
bacilli, 79, 292, 296; in stools, 85, 
96; streptococcus, 302 

Barley water (see Cereal diluents) 

Barlow's disease (see Scurvy) 

Baths, cold pack, 315; fan, 315; 
sponge, 315 

Bauer's reaction, 129 

Beef juice, 247 

Beriberi, effect on human milk, 128 

Bile, 17, 18; in human milk, 128; min- 
eral salts in, 59 

Bile ducts, obliteration of, 30, 92 

Bismuth, 296, 313 

Blood, dextrose in, 36; lecithin in, 22; 
in rickets, 337; in stools, 94 

Bluhdorn on bacteriology of intes- 
tines, 84 

Brain, hemorrhage, 300 

Bran, 326 

Bread and zweibach, 248 

Breast, care of, 141; influence of 
ovary on, 126 

Breast-fed infant, abnormal, 144; 
normal, 143 

Breast feeding (see Feeding, breast) 

Breast glands, 103 

Breast milk (see Milk, human) 

Breast pumps, 141 

Breck feeder, 140, 253 

Broths, 248 

Buttermilk in artificial feeding, 218, 
220; stools, 90 

Butyric acid, 78 

Butyric acid bacilli, 79, 292, 297 

Cabbage, 346 

Calcium in cow's milk, 332; in human 
milk, 121; metabolism of, 59, 287, 
333; metabolism in rickets, 332; 



377 



378 



INDEX OF SUBJECTS 



metabolism in spasmophilia, 354; 
requirements of, 333 

Calomel, 288, 295, 308, 327, 365; 
stools from, 288 

Calories (see also Energy metab- 
olism), caloric value of cow's milk, 
177; caloric value of human milk, 
122; caloric values, 71, 239; deter- 
mination of values, 239; require- 
ments, 71, 75, 198; requirements by 
premature infants, 72 

Calorimetry, 65 

Carbohydrates, caloric values of, 71; 
decomposition by bacteria, 36; 
digestion and metabolism of, 32, 35, 
38; excessive amount of, 42, 54; 
forms of, 34, 35; ferments, 32, 130; 
indigestion, 97, 275; influence on 
calcium metabolism, 61, 335, 338; 
influence on protein metabolism, 
37, 54; respiratory quotient, 71 

Cascara sagrada, 327 

Casease, 129 

Casein, 11; action of rennin on, 162; 
analysis of, 114; chemistry of, 162, 
167; coagulation of, 48; in cow's 
milk, 167, 215; curds, 20, 46, 47, 93, 
211, 215, 286; effect of alkalies on, 
163; in human milk, 113, 215; 
indigestion, 98, 285; phosphorus 
in, 115; sulphur in, 115 

Castor oil, 287, 295, 300, 308, 327, 365 

Catharsis, 288, 295, 324, 325, 327 

Cereal diluents, action of, 212, 216; 
in artificial feeding, 212; prepara- 
tion of, 235 

Cereals in infant feeding, 247 

Chlorides in human milk, 121; me- 
tabolism of, 61 

Cholera bacillus in stools, 86 

Cholera infantum, 91, 317 

Chvostek's sign, 354 

Chymosin (see Rennin) 

Citric acid in cow's milk, 170; in 
human milk, 122 

Cod-liver oil, 290, 338, 359 

Colic, 289 

Colon, irrigation of, 296, 312 

Colostrum, 103; amount of, 136; ash 
of, 120; composition of, 104, 105, 
123; corpuscles, 105; of cow's milk, 
157; hemolysin in, 133; human, 104; 
opsonins in, 133; protein of, 106 



Coma in infectious diarrhea, 315 
Constipation, 321; atonic, 324; etiol- 
ogy of, 321 ; fat in, 323; fruit in, 249; 

heredity in, 321; mechanical, 322; 

in newborn, 321; spasmodic, 322; 

starch in, 212, 323; treatment of, 

325 
Convulsions (see also Spasmophilia) 

in infectious diarrhea, 316 
Corpus luteum a galactagogue, 125 
Cream, 205, 229 
Cretinism, 322 
Curds, casein, 20, 46, 47, 93, 211; 

fat, 93; methods of prevention, 

215, 286 
Cystin, 57 

Davidsohn's reaction, 128 

Dextrin, 35 

Dextrin-maltose mixtures in artificial 
feeding, 206; in constipation, 326; 
in indigestion, 278; indigestion 
from, 279; stools on, 90; table of 
various forms, 206 

Dextrose, 35; infusions, 310 

Diarrhea, carbohydrate in, 37; cause 
of acidosis, 363; dysentery bacillus 
in, 86; etiology of, 49; fat, 27; fer- 
mentative, 292; in fermentative in* 
digestion, 293; infectious, 291, 294, 
302; mineral salts in, 62; nervous 
disturbances, 267; relation to breast 
feeding, 99; stools in, 62; strep- 
tococcus in, 86 

Diastase, 2, 32, in stools, 33 

Digestants, 289 

Digestion, carbohydrate, 32; dis- 
turbances of, 269; fat, 20; gastric, 
6; intestinal, 19; leucocytosis dur- 
ing, 19; mineral salts in, 59; pan- 
creatic, 14; physiology, 1; protein, 
43; salivary, 2 

Digestive tract, diseases of, 255; 
nervous disturbances of, 267 

Drugs, excretion in human milk, 126 

Dysentery bacillus in cow's milk, 176; 
in stools, 86 

Eggs, 249 

"Eiweissmilch" (see Albumin milk) 
Enemata, 327 

Energy metabolism, 64; basal metab- 
olism, 75; and body surface, 67; 



INDEX OF SUBJECTS 



379 



and body weight, 68; effect of 

exercise, 66; effect of fasting, 66; 

methods of computing, 65 
Enterokinase, 16, 44 
Epilepsy, as contraindication to 

nursing, 101 
Erepsin, 16, 18, 45 
Exercise, effect on metabolism, 66 
Exudative diathesis, 31 

Fasting, metabolism in, 53, 66 

Fat, absorption of, 20, 25; Babcock 
test for, 229; caloric value of, 71, 
239; in cow's milk, 169; curds, 93; 
diarrhea, 27; digestibility of, 21; 
digestion and metabolism, 20; 
effect on mineral metabolism, 61, 
334, 338; effect on nitrogen me- 
tabolism, 53; excessive percentage 
of, 204; homogenization of, 203; 
in human milk, 115; indigestion, 97, 
272; respiratory quotient of, 71; 
staining properties of, 96; in stools, 
23, 24, 25, 26, 27, 30, 95 

Feces, (see Stools) 

Feeding, artificial: albumin milk in, 
222; alkalies in, 216; amount of 
food in, 200; buttermilk in, 218, 
220; calcium in, 332; caloric basis 
of, 198, 239; cow's milk in, 194; 
fat in, 203; formulae for, 231; gen- 
eral principles, 192; goat's milk in, 
194; indigestion from, 271, 273, 
276, 280, 284; interrelation of va- 
rious foods, 219; intervals in, 200, 
202; milk the basis of, 193; mineral 
salts in, 219; mortality in, 99; pan- 
creatization in, 219, 241; percent- 
age calculations, 197, 238; poly car- 
bohydrates in, 213; proprietary 
foods in, 241; protein in, 213, 240; 
regularity in, 200; relation to 
rickets, 330; relation to scurvy, 343; 
special milk preparations in, 220; 
starch in, 210, 235; stools in, 89; 
sugars in, 205; variation at dif- 
ferent ages, 202; variation of food 
elements, 203; whey mixtures in, 
215, 236 

Feeding, breast, ability to nurse, 100, 
134; amount at single nursing, 139, 
145; calcium in, 332; causes of 
failure to nurse, 134; clinical con- 



siderations and technique, 134; 
contraindications to, 101; difficul- 
ties of, 140; duration of single 
nursing, 139; in first days, 136; 
indigestion from, 270, 272, 275, 
282; indirect method of, 156; mor- 
tality in, 99; normal results of, 
143; regularity in, 138; relation to 
digestive disturbances, 270; rela- 
tion to rickets, 330; relation to 
scurvy, 343; relative frequency of, 
100; stools in, 88; transmission of 
immunity through, 132 

Feeding during second year, 246, 
324 

Feeding intervals on artificial food, 
200; on breast, 138 

Feeding, mixed, 135, 148 

Feeding, percentage (see Percentage 
feeding; 

Ferments, amylolytic, 32; carbohy- 
drate splitting, 32, 130; fat split- 
ting, 20, 130; gastric, 9, 32, 43; in 
human milk, 291; intestinal, 19, 
33, 44; in milk, 129, 130, 131, 181; 
pancreatic, 14, 32, 44; proteolytic, 
43, 129; salivary, 2, 32, 43; sabol- 
splitting, 131; in stools, 33 

Fever, in cholera infantum, 318; in 
fermentative indigestion, 294; in 
infectious diarrhea, 204, 307; in 
lactose indigestion, 277 

Fibrinogen in human milk, 130 

Flatulence, 289 

Fruit juices, 249, 326, 352 

Galactagogues, 125, 147 
Galactose, 35 
Gastric (see Stomach) 
Gastrointestinal canal, bacteriology 

of, 77; diseases of, 255 
Globulin in cow's milk, 168; in human 

milk, 113 
Glycemia, 36 
Glycocoll, 57 
Glycogen, 35 

Hemolysin in human milk, 133 
Hemorrhages as contraindication to 

nursing, 102; in scurvy, 342 
Hemorrhoids, 322 
Hirschsprung's disease, 322 



380 



INDEX OF SUBJECTS 



Hydrochloric acid, 11, 43, 78 
Hyperpyrexia, 315 

Ice cap, 315 

Idiosyncrasy to cow's milk, 194 

Immunity, transmission through 
milk, 132 

Inanition fever, 300 

Indigestion, artificial food, 271, 273, 
276, 280, 284; breast milk, 270, 272, 
275, 282; carbohydrate, 97, 275; 
casein curds in, 48; classification of, 
270; dextrin-maltose, 279; differ- 
ential diagnosis of, 294; etiology of, 
269; excessive food, 270; excite- 
ment, 268; fat, 272; fermentative, 
291; lactose, 276; mixed forms of, 
98; protein, 55, 98, 282; saccharose, 
279; salts, 286; starch, 280; stools 
in carbohydrate, 275, 276, 279, 280; 
stools in fat, 282, 283; stools in 
fermentative, 293; stools in pro- 
tein, 283, 284, 285; treatment, 287, 
295 

Infant mortality, 99 

Infantile atrophy, 28; anaphylaxis in, 
50; nitrogen retention in, 55 

Insanity as contraindication to nurs- 
ing, 101 

Intestinal fermentation, 222, 291 

Intestines, antiferments of, 44; atresia 
of, 321; bacteriology of, 36, 38, 79, 
83; changes in indigestion, 292; 
changes in infectious diarrhea, 303; 
digestion in, 36; endogenous infec- 
tion of, 80; ferments of, 33; 
hemorrhage of, 94; length of, 18; 
mineral salts in, 59; nervous dis- 
turbances of, 267; reaction of, 18; 
secretions of, 18; small, 18 

Intussusception, differential diagno- 
sis of, 306; stools in, 94 

Inunctions, 290 

Invertin, 18, 19, 33 

Iron in human milk, 121; metabolism 
of, 60 

Jackson's membrane, 322 
Jaundice, effect on human milk, 128 

Kidneys in acidosis, 363, 365; in 
fermentative indigestion, 292; in 
infectious diarrhea, 303 



Laboratories, milk (see Milk labora- 
tories) 

Lactalbumin, 57; in cow's milk, 168; 
in human milk, 113 

Lactase, 19, 33 

Lactic acid, 78 

Lactoglobulin, 168 

Lactose, in artificial feeding, 205; 
in cow's milk, 169; effect on gastric 
motility, 35; in human milk, 119; 
indigestion from, 209, 276; toler- 
ance of, 41 

Laryngismus stridulus, 354 

Laxatives, 327; abuse of, 324 

Lecithin in cow's milk, 169; in human 
milk, 119, 121 

Lemon juice, 346, 352 

Leucocytosis: in fermentative in- 
digestion, 293; in infectious di- 
arrhea, 305 

Levulose, 35 

Lime water, 12, 165, 217; action of, 12 

Lipanin, 339 

Lipase, 10, 14 

Lipemia, 23, 365 

Liver, 16; in fermentative indigestion, 
292; glycogenic function of, 35; in 
infectious diarrhea, 303; iron in, 60; 
weight of, 16, 17 

Lysin, 57 

Magnesia, "milk of," 288, 308, 327 

Magnesium : metabolism of, 60 

Magnesium sulphate, 359 

Malnutrition: constipation in, 324 

Maltase, 19, 33 

Malted foods, 243 

Maltose, 35; in artificial feeding, 207; 

indigestion from, 279; stools from, 

90 
Marasmus (see Infantile atrophy) 
Meat, 249 
Meat broths, 248 
Meconium, 88; bacteriology of, 81; 

ferments of, 33, 44; retention of, 

137; toxic products of, 298 
Megacolon, 322 
Melena neonatorum, 300 
Meningitis, 300, 307 
Menstruation, effect on human milk, 

127; relation to weaning, 150 
Metabolism, 1; basal, 64, 75; and 

body surface, 67; carbohydrate, 38; 



INDEX OF SUBJECTS 



381 



energy, 64; exercise in, 66; fasting, 
66; fat, 20, 24; gaseous, 64; mineral 
58; in newborn, 74; protein, 53; 
in scurvy, 348; in starvation, 
75 

Milk, certified, 189; coagulation of, 
48; comparative absorption of pro- 
teins, 51; composition in different 
animals, 172 

Milk, cow's, acidity of, 159; action of 
rennin on, 161; alexins in, 181; 
anaphylaxis to, 50; appearance of, 
158; bactericidal power of, 181; 
bacteriology of, 175, 181; calcium 
in, 332; caloric value of, 177; 
casein in, 160, 167, 215; certified, 
189; chemistry and biology of, 
157, 165; citric acid in, 170; co- 
agulation of, 159; colostrum of, 
157; comparison with human, 195; 
comparison of raw and pasteurized, 
182; comparison of various breeds, 
166, 196; condensed, 243; effect of 
freezing on, 171; effect of heating 
on, 179, 182, 186, 216, 323, 336, 
344; extractives in, 168; fat in, 
116, 168, 203, 229; fatty acids in, 
118; ferments in, 181; idiosyncrasy 
to, 50, 194; lactalbumin in, 168; 
lactoglobulin in, 168; lactose in, 
169; lecithin in, 169; microscopy 
of, 158; mineral salts in, 169, 219; 
mixed, 196; modification of, 149, 
195; nitrogenous bodies of, 165; 
pancreatization of, 241; paracasein 
in, 167; pasteurization of, 179, 186; 
phosphorus in, 122; precipitation 
with acids, 159; preservatives in, 
177; proteins of, 215; reaction of, 
158; smell of, 158; solids of, 229; 
specific gravity of, 158; steriliza- 
tion of, 179; stools from, 89; taste 
of, 158; vitamins in, 349; whey of, 
168, 215 

Milk, fat free, 230 

Milk, goat's, 173, 194 

Milk, home modification of, 226; 
calculation of formulae, 231; cal- 
culation of starch mixtures, 235; 
calculation of whey mixtures, 236; 
composition of materials in, 229; 
determination of caloric value, 239; 
determination of percentages, 238; 



determination of protein content, 
240; pancreatization in, 241 

Milk, human, abnormal types of, 142, 
146; agglutinins in, 133; albumin- 
ous bodies in, 113; alcohol in, 127; 
analysis of, 143; antibodies in, 132; 
antitoxin in, 132; bactericidal sub- 
stances in, 133; bacteriology of, 
106; beriberi in relation to, 128; 
bile in, 128; calcium in, 121, 332; 
caloric value of, 122; casein in, 113, 
114; characteristics of, 107; chem- 
istry of, 103, 111, 123, 172; chlo- 
rides in, 121; citric acid in, 122; 
coagulation of, 110, 111; color of, 
107; comparison with cow's, 195; 
diet in relation to, 124, 146; dif- 
ferentiation of, 128; elimination of 
drugs in, 126; estimation of amount 
of, 145; fat in, 115, 116, 117, 118; 
fatty acids in, 118; ferments in, 129; 
foreign bodies in, 126; globulin in, 
113; hemolysin in, 133; influences 
on secretion of, 127; iron in, 121; 
lactalbumin in, 113; lactose in, 119; 
lecithin in, 119; menstruation in 
relation to, 127; microscopy of, 107; 
mineral salts in, 119, 120, 219; 
modification of, 146; nephritis in 
relation to, 128; nervousness in 
relation to, 127; nitrogenous bodies 
in, 111, 112, 113, 114; nuclein in, 
119; opalisin in, 114; opsonins in, 
133; phosphorus in, 115, 121; 
pigments of, 117; preservation of, 
156; proteins of, 111, 112, 113, 114, 
215; quality of, 142; quantity of 
secretion, 108, 109; reaction of, 
108; residual nitrogen of, 113; 
"running in" of, 134; specific 
gravity of, 108; stools from, 88; 
toxins in, 132; transmission of 
toxins and immunity through, 132; 
uremia in relation to, 128; varia- 
tions in composition of, 123; 
viscosity of, 122; vitamins of, 349; 
whey of, 215 

Milk, modified, prescribing of, 225 

Milk, skimmed, 230, 233; stools 
from, 89 

Milk laboratories, 226 

Milk poisoning, 182 

Milk sickness, 177 



3S2 



INDEX OF SUBJECTS 



Milk sugar (see Lactose) 

Mineral salts, in cow's milk, 169; 
in human milk, 119, 120; indiges- 
tion from, 219, 286; influence of 
food elements on metabolism of, 
61; influence on calcium metab- 
olism, 335; loss in fat indigestion, 
273; metabolism of, 58; metabo- 
lism in scurvy, 348; metabolism in 
spasmophilia, 356; relation of 
cedema to, 62; utilization of, 59 

Moro's reaction, 128 

Mouth, bacteriology of, 1, 77; care of, 
141; deformities in relation to 
nursing, 140; digestion in, 2; fer- 
ments of, 2; reaction of, 1 

Mucus, in stools, 93 

Nephritis, as cause of acidosis, 363; 
effect on human milk, 128 

Nervous irritability in infectious di- 
arrhea, 315; in protein indigestion, 
284 

Nervousness, effect on human milk, 
127, 148 

New-born infant, constipation in, 
321; intestinal toxemia in, 298; 
metabolism of, 74 

Nipple shields, 141 

Nipples, care of, 140 

Nitrogen (see Protein) 

Nuclein in human milk, 119 

Nucleon in human milk, 121 

Nursing, amount at single, 139, 145; 
causes of failure, 134; difficulty in 
technique, 140; duration of single, 
139; intervals between, 138; 
method of, 138, 141; during night, 
138; regularity of, 138 

Nutrition, diseases of, 329 

(Edema, relation of, to salts, 62; in 

scurvy, 342 
Oils, inunction of, 290 
Olive oil, 28; in constipation, 327 
Opalisin in human milk, 114 
Opium, 313 

Opsonins, in human milk, 133 
Orange juice, 247, 352 
Ovary, influence on breast, 126 
Oxydase, in milk, 131 

Pancreas, 14; ferments of, 32, 44; 



influence on glycogen absorption, 
35; mineral salts in, 59; secretions 
of, 14; size of, 14, 15 

Pancreatization of food, 219, 241 

Paracasein, 167 

Paratyphoid bacillus in stools, 86 

Parathyroid glands, in spasmophilia, 
354, 357 

Parotid gland, 2 

Pasteurization of milk, 179 

Pepsin, 9, 13, 43; in milk, 129 

Peptonization of food, 219, 241 

Percentage feeding, 197; calculations 
in, 231, 238 

Peroxidases, 131 

Phosphorus, 359; in human milk, 121; 
metabolism of, 60, 336, 362; in 
rickets, 339 

Pineal extract, as galactagogue, 125 

Pituitary extract, as galactagogue, 
125 

Placental extract, as galactagogue, 
125 

Polycarbohydrates, 213 

Posture, influence on digestion, 9 

Potassium, influence on calcium me- 
tabolism, 336; metabolism of, 61 

Potato, 249, 352 

Pregnancy, in relation to weaning, 
150 

Premature infant, amount of food for, 
253; caloric needs of, 251; char- 
acter of food for, 252; extrabuccal 
feeding of, 253; feeding intervals, 
251; human milk for, 250; inability 
to nurse, 102; metabolism of, 250; 
methods of feeding, 253; secretions 
of, 250; water need of, 253 

Proctoclysis, 367 

Proprietary foods, 241; relation to 
scurvy, 343 

Prostration, 316, 317 

Protein, absorption of, 46; in artificial 
feeding, 213; caloric value of, 71, 
239; determination in modified 
milk, 240; digestion of, 43; exces- 
sive amount of, 214; excretion of, 
52, 53; in human milk, 111, 112, 
113, 114; indigestion, 98, 282; in- 
fluence of carbohydrates on, 37; 
influence on calcium metabolism, 
334; metabolism of, 43, 53; need of 
infant, 56, 192, 214; relative value 



INDEX OF SUBJECTS 



383 



of, 57; respiratory quotient of, 71; 
sensitization to, 51; sparing of, 
37, 38, 54; utilization of, 54, 55; 
vegetable, 214 

Protein milk (see Albumin milk) 

Proteolysis, 45, 46 

Ptyalin, 2 

Puerperal eclampsia, as contraindica- 
tion to nursing, 102 

Purgatives, 327 

Pus, in stools, 94 

Pylorus, action of, 8; spasm of, 20, 
255, 262; stenosis of, 256, 259 

Pyocyaneus bacillus, 302 

Rectum, imperforate, 321 

Reductase, 131 

Rennin, 10, 13, 43; action on boiled 
milk, 216; action on cow's milk, 
161; action on human milk, 110; 
effect of lime water on, 165; effect 
of sodium citrate on, 164 

Respiratory quotient, 70 

Rickets, 329; chemistry of, 334; con- 
stipation in, 324; etiology of, 330; 
experimental, 331; heredity in, 330; 
infectious origin of, 330; internal 
secretions in, 331; metabolism in, 
332; pathology of, 329; phosphorus 
metabolism in, 336; relation to 
heated milk, 184; treatment of, 337 

Saccharose, 35; in artificial feeding, 
210; indigestion, 279 

Saliva, amount of, 3; ferments of, 32, 
43 

Salivary glands, 1 

Salt solution, 314 

Salvarsan, excretion in human milk, 
127 

Scarlatina, transmission by cow's 
milk, 176 

Sclerema, 318 

Scurvy, 247; etiology of, 343; ex- 
perimental, 345; metabolism in, 
348; pathology of, 341; relation to 
heated milk, 184; treatment of, 
351; vitamins in, 349 

Secretin, 15, 44 

Sedatives, 316 

Sellards' test, 364 

Senna, 327 

Sepsis in newborn, 300 



Sleep, of breast fed, 144 

Soap enema, 327 

Soap stools, 25, 26, 27, 323 

Sodium, influence on calcium metab- 
olism, 335; metabolism of, 61, 287 

Sodium bicarbonate, 367; action of, 
12; in artificial feeding, 218 

Sodium chloride, pyrogenic effect of, 
40,41 

Sodium citrate, action of, 12; in 
artificial feeding, 218; effect on 
rennin, 164 

Sodium phosphate, 327 

Spasmophilia, calcium metabolism in, 
355; in fat indigestion, 274; hered- 
ity in, 354; parathyroids in, 357; 
treatment of, 358 

Starch, 35; in artificial feeding, 210; 
caloric value of, 239; as cause of 
constipation, 212, digestion of, 2, 
3; excessive amount of, 212; in- 
digestion from, 97, 280; mixtures, 
235; as protective colloid, 211; 
in stools, 94, 95 

Starvation, acidosis in, 363; metab- 
olism in, 75; stools in, 52, 90 

Steapsin (see Lipase) 

Stimulants, 314, 316, 319 

Stomach, 3; absorption in, 13; acidity 
of, 12; air in, 9; bactericidal powers 
of, 78; bacteriology of, 78; butyric 
acid in, 78; capacity of, 4; cathe- 
terization of, 288; digestion in, 6; 
dilatation of, 263; ferments of, 32; 
growth of, 3; hydrochloric acid in, 
11; influence of posture on, 9; 
lactic acid in, 78; motility of, 7; 
nervous disturbances of, 267; posi- 
tion of, 3; pyloric spasm, 255; 
pyloric stenosis, 259; secretions of, 
9 

Stools, 87; abnormal constituents of, 
93; animal food, 90; of artificially 
fed, 89, bacteriology of, 81, 85, 96; 
black, 93; blood in, 94; blue, 93; 
of breast-fed, 88, 143; buttermilk, 
90; calcium in, 334; in carbohy- 
drate indigestion, 275, 276, 279, 
280; in casein indigestion, 285; 
in cholera infantum, 317; color of, 
92; cow's milk, 89; curds in, 48, 
93; dextrin-maltose, 90; fat in, 23, 
24, 25, 26, 27, 30, 92, 95, 97; in fat 



384 



INDEX OF SUBJECTS 



indigestion, 272, 273; in fermenta- 
tive indigestion, 293; ferments of, 
33, 44; gray, 92; green, 92; in in- 
digestion, 97; in infectious di- 
arrhea, 303; in intussusception, 306; 
membranes in, 94; microscopic 
examination of, 94; mucus in, 91, 
93; nitrogen in, 52; odor of, 91; 
phosphorus in, 336; pink, 93; in 
protein indigestion, 283, 284, 285; 
pus in, 94; reaction of, 91; salts in, 
27; slammed milk, 89; starch in, 
94, 95, 97; from starch, 89; in 
starvation, 52, 90; in stenosis of 
pylorus, 264; sugar in, 36; whey, 89; 
white, 92 

Submaxillary glands, 2 

Sucking, mechanism of, 1 

Sugars, absorption, limits of, 41; 
in artificial feeding, 205; caloric 
value of, 239; excretion of, 38, 39; 
fever, 206; forms of, 35; indigestion 
from, 276; intestinal fermentation 
of, 222; intoxication by, 40, 41; 
laxative action of, 38, 206 

Sulphur, metabolism of, 61, 362; 
metabolism in scurvy, 348 

Superoxidase, 131 

Suppositories, 325, 327 

Syphilis, transmission by breast milk, 
107 

Tenesmus, treatment of, 313 
Tetany, 354, experimental, 355; 

parathyroid, 357 
Thymus, in rickets, 331 
Thyroid, in constipation, 321; in 

rickets, 331 
"Top milk," 205, 230 
Toxemia, intestinal, 298; acidosis in, 

365; in infectious diarrhea, 314 
Toxins, transmission through human 

milk, 132 
Trembles, 177 
Trousseau's sign, 354 
Trypsin, 10, 14, 44; in milk, 129 
Trypsinogen, 16, 44 
Tryptophan, 57 



Tubercle bacillus, in cow's milk, 176; 

in stools, 86 
Tuberculosis, as contraindication to 

nursing, 101 
Tuberculous peritonitis, 30 
Tugendreich's reaction, 129 
Typhoid bacillus, in cow's milk, 176; 

in stools, 85 

Umikoff's reaction, 128 
Uremia, effect on human milk, 128 
Urine, acetone bodies in, 363; cal- 
cium in, 334; in cholera infantum, 
318; in fermentative indigestion, 
293; in infections diarrhea, 305; 
nitrogen in, 53 

Vasomotor paralysis, 318 

Vegetables, in constipation, 326; in 
diet, 249; in scurvy, 346 

Vitamins, 56, 349 

Vomiting in acidosis, 364; in carbo- 
hydrate indigestion, 275; in casein 
indigestion, 285; in cholera infan- 
tum, 317; habitual, 264; in indiges- 
tion, 288; in infectious diarrhea, 
315; in lactose indigestion, 277; 
in nervous disturbances, 267; after 
nursing, 142; in pyloric spasm, 256; 
in pyloric stenosis, 260; whey 
mixtures in, 216 

Weaning, 149; age for, 151; diet after, 
246; indications for, 149; menstrua- 
tion in relation to, 150; pregnancy 
in relation to, 150; in summer, 151; 
technique of, 151 

Wet-nurses, general considerations, 
153; management of, 155; methods 
of procuring, 156; protection of, 
154; qualifications of, 154 

Whey, 57; chemistry of, 168; of cow's 
milk, 215; of human milk, 215; 
indigestion from, 284; preparation 
of, 238; protein of, 162, 215; stools 
from, 89 

Whey mixtures, 215, 236; for pre- 
mature infants, 252 



Printed in the United States of America 



